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Safety Management Systems for Airports, Volume 2: Guidebook (2009)

Chapter: Chapter 6 - SMS Operation

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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Suggested Citation:"Chapter 6 - SMS Operation." National Academies of Sciences, Engineering, and Medicine. 2009. Safety Management Systems for Airports, Volume 2: Guidebook. Washington, DC: The National Academies Press. doi: 10.17226/14316.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Once the SMS is in place, it needs to be managed; this includes on-going monitoring of system performance, as well as the development and implementation of plans for continuous improvement. On-going management will ensure that the SMS and associated processes are working to improve the level of safety. This should include setting new objectives, continually running the SMS processes, and developing and implementing a plan for improvement initiatives over a given period (e.g., for the next year). Use the outputs from other elements of the system to evaluate how your SMS is performing (performance measurement, management review, etc.) Once you have identified opportunities for improvement, develop plans to achieve these improvements. This chapter was designed to help you with the SMS operation. You will identify the major tasks associated with SMS activities and find out more details about the role of an SMS Manager. Moreover, this chapter contains basic concepts and practical guidance on the following: • Typical tasks for the SMS operation • Safety culture and how to promote it • Useful techniques for safety meetings • How to establish a safety reporting system • Techniques for accident and incident investigations • Procedures for internal safety and SMS assessments • Guidance for safety performance monitoring • Basic guidelines to establish an SMS training program 6.1 Major Tasks for the SMS Operation The SMS Manager will be responsible for running the SMS operation. Depending on the size and complexity of your airport, this person may be a full-time SMS Manager, may or may not have staff to support the SMS activities, or may have additional functions at the airport. The SMS Manager should guarantee the execution of the tasks indicated in Table 17. (Note that these tasks are related to the four SMS pillars and the respective elements described in Chap- ter 2.) This list is not exhaustive; however, many of the tasks are simple to execute, particularly at smaller airports. 6.2 Safety Culture and Promotion Effective safety management requires more than a safety office and safety procedures. The safest organizations have something that is difficult to describe and quantify but, when it is there, it is perceptible and obvious. It is the way that the organization and the people within it 89 C H A P T E R 6 SMS Operation

90 Safety Management Systems for Airports Table 17. Major tasks for SMS operation. SMS Pillar Element Tasks to be carried out or coordinated by the SMS Manager Be alert to any change in the airport organizational structure and its impact on the SMS structure Organizational Structure Be sure that all the interfaces among the stakeholder activities work toward the SMS operation Documentation Make sure that all the documentation is managed as required by the SMS Policies and Objectives Coordination of the Emergency Plan Constantly evaluate the interfaces between AEP, airlines, and ATC emergency plans. Assist with recommendation to improve the AEP. Continuously check the compliance of the procedures for collecting, recording, acting, monitoring and providing feedback on hazards and mitigation actions, considering both reactive and proactive approaches Collect, compile, and check the effective use of the mandatory, voluntary, and confidential reporting systems, according to the airport policy Create adequate environment for the compliance of the reporting systems Continuously improve the reporting systems to make them simple, confidential, accessible, informative, and with rapid feedback Collect, organize, and store hazard data and safety reports Hazard Identification Analyze, consolidate essential data, and provide feedback on hazard reports Coordinate and carry out risk assessments with multidisciplinary groups, and help delineate risk mitigation strategies Risk Assessment Be sure that all the activities related to hazard identification, risk assessment, and mitigation processes are developed according to the processes defined in the SMS documentation Delineate procedures to evaluate the effectiveness of mitigation actions Corrective Actions and Monitoring Coordinate continuous monitoring of identified hazards and the effectiveness of mitigation actions Ensure the reporting processes are available and working properly Safety Risk Management Reporting Systems Assist the Accountable Executive with making sure the airport complies with the established reporting policy Internal Safety Investigations Coordinate the internal investigations to determine root causes for occurrences or events that are not required to be investigated by organizations outside the airport (e.g., NTSB, FAA) Constantly analyze available safety information obtained during the SMS operation to determine the need to create or improve SOPs Improving SOPs Assist with the creation and improvement of SOPs Analyze the need to conduct assessments on the impact of future changes in the airport environment such as construction, introduction of new equipment, introduction of new regulatory requirements and processes, changes in security, reorganization of air traffic control, changes to the airport organization, etc. Assessing the Impact of Changes Monitor risk control actions taken Ensure that the airport collects data for all performance indicators defined in the SMS documentation Assist and conduct trend analysis for each performance indicator Monitor SPI trends and evaluate safety performance to suggest actions Identify the hazard(s) behind performance indicator trends that point out safety deficiencies Performance Monitoring Identify and assist identifying appropriate potential performance indicators Plan and coordinate internal assessments according to the SMS requirements, help prepare checklists, coordinate the organization of the teams When necessary, help with the analysis and compilation of the information Assist with the Identification of areas that need more attention Ensure that every airport department receives a summary of the SMS assessment Use safety surveys to check the SMS operation in terms of problem areas or bottlenecks in daily operations, perceptions, and opinions of operational personnel, areas of dissent, or confusion Safety Assurance Internal SMS Assessment Ensure that recommended actions that have been approved are adequately implemented

behave—their safety culture(29),(30). Safety culture is not an isolated SMS pillar or element, but it is an essential feature of any effective SMS and should permeate the whole organization to bind its SMS pillars. All of the airport SMS pillars and elements contribute toward a strong safety culture. It is not the intent of this section to repeat the discussion of these elements, but instead to focus on spe- cific aspects, features, programs, and activities that are aimed specifically at enhancing safety cul- ture. This section describes what safety culture is and how it can be promoted and enhanced at your airport. Building a strong safety culture requires key organizational activities that promote a high level of risk awareness on the part of the employees and a sense of personal responsibility for reduc- ing risk. Senior management commitment and demonstrated leadership in promoting safety are essential ingredients in the enhancement of a strong safety culture. General Concepts and Principles The safety culture concept comes from decades of research on how accidents happen. Before the 1970s, investigations focused on technological failures, adverse weather conditions, and human errors as root causes of aviation accidents. Eventually, investigators and researchers SMS Operation 91 SMS Pillar Element Tasks to be carried out or coordinated by the SMS Manager Ensure that adequate information is provided for the Management Review Advise the airport high level administrative personnel before, during, and after the Management Review Put in practice the strategic plan for safety improvement developed by the Management Review Management Review Monitor the strategic plan for safety improvement Ensure that all staff levels receive adequate indoctrination and recurrent training, including airport stakeholders when it is the case Identify the areas most in need of additional training Identify the necessary resources to meet training needs Ensure the SMS training program is implemented Training and Education Assist measuring SMS training effectiveness Develop formal means for safety communication within the SMS environment Make sure that employees are involved or consulted in the development and review of policies and procedures implemented to manage risks Make sure that safety information is disseminated throughout the organization Safety Communication Create processes to assess the effectiveness of safety communication Ensure the application of the concepts behind the PDCA (Plan, Do, Check and Act) Periodically revise the SMS self-assessment and find out areas where improvement is necessary Check all regular, periodic, and planned reviews regarding safety processes and performance Safety Promotion Safety Assurance Continuous Improvement Monitor the decisions and actions aimed at improving safety to evaluate their effectiveness Keep close coordination with the SMS Champion if there is one Other Tasks Help the line managers with their safety programs Coordination of safety items in meeting agendas Participate in the airport safety meetings Develop, assist, and coordinate safety promotion initiatives Assist with obtaining the necessary resources to carry out mitigation actions, training, and other tasks associated with SMS Ensure the necessary resources are allocated to the SMS operation Table 17. (Continued).

began to understand that errors could be triggered by a number of additional factors, such as communications problems, decision-making issues, and lack of effective coordination within the organization. In other words, there are often latent causes of errors that are attributable to the organizational environment and that make individual errors more likely. Elements of Safety Culture In an informed culture, workers understand the hazards and risks involved in their tasks, which are the inherent dangers of their working environment. They also understand how their work may have an impact on the safety of other tasks and of the airport in general. Employees continuously monitor operations to identify new or previously unrecognized hazards. In a reporting culture, employees and other stakeholders are encouraged to report safety concerns. They do so without fear of being punished or ridiculed. When safety concerns are reported, they are analyzed, appropriate action is taken, and feedback is always provided. Note that it is advisable to seek Legal counsel when establishing a reporting system that is intended to be confidential and/or non-punitive, as it needs to be fully compliant with applicable laws. In a just culture, management recognizes that most errors are unintentional and makes an effort to understand and correct the conditions of work that make errors more likely. However, when errors are the result of a blatant disregard of rules, malicious intent or gross negligence, punishment is deliberate and fair. For this to work, airport employees must clearly understand what is punishable and what is not. In a flexible culture, employees do not blindly apply procedures. They are capable of identi- fying the intent of the procedures and understanding the safety envelope. They are therefore able to adapt to changing situations while respecting the safety goals. They are also effective, with appropriate training, in responding to the introduction of new technologies or equipment. A learning culture is one that is characterized by a questioning attitude aimed at continuous improvement. Employees at all levels constantly ask themselves and each other: “how could we do this better?” All employees are encouraged and empowered to develop and apply their own experience and knowledge to enhance airport safety. Lessons from errors and incidents are iden- tified, shared, and learned. This means that lessons identified are analyzed and that, when required, risk control actions are taken. It also means that management keeps personnel updated on safety issues and risk control actions taken. What Does a Strong Safety Culture Look Like? Safety culture is difficult to quantify, but the following examples provide an idea of what would be expected in an organization with a strong safety culture compared with a weak safety culture. These are examples only; safety culture characteristics can take several forms depending on the organization. Some typical signs of strong and weak safety cultures are depicted in Table 18. 92 Safety Management Systems for Airports It is important not to confuse non-punitive with accountability. People must remain accountable for their actions, even in a non-punitive environment. According to James Reason(31), a safety researcher from the United Kingdom, safety culture has five key characteristics: it is informed, reporting, learning, just, and flexible.

SMS Operation 93 In a strong safety culture In a weak safety culture Employees are proactive; they continually identify unsafe situations and make an effort to correct them before they become a real problem. Employees never question procedures they know to be outdated or recommend new procedures that are safer and more effective. Employees feel that safety is their responsibility and that they have the power to do something about it. Employees believe that safety is the responsibility of the supervisors or the safety officers. There are clear policies and procedures that spell out expectations for safety, and the employees understand and believe in them. There is a safety policy but most people think it is lip-service and window dressing. Employees truly understand the risks involved in their work. Employees accept procedures without really understanding why. They do not understand all the risks. Proactive risk assessment is an integral part of the way the organization manages business, before incidents or accidents happen. Risk is only evaluated after something bad has happened. The behavior of employees reflects what the safety policy proclaims. Employees and managers say one thing, but their actions reflect a different belief. Personnel receive feedback on safety issues and safety reports. Safety issues may be analyzed but employees are never really told what was done to address the issue. Managers and supervisors promote a questioning attitude regarding safety issues on the part of all employees. Through their actions and behavior, supervisors and managers let it be known that questioning management decisions is not a good thing. Safety is an integral part of operations management and line managers are clearly responsible. Safety is seen as the responsibility of a safety office, and their interventions are often perceived as a nuisance to operations. Upper management takes an active role in safety activities and promotion. Senior managers delegate their safety functions to a junior manager. They may show occasional interest, but people know that safety is only important as long as it does not affect operations. All employees believe that safety does not have to come at the cost of productivity or profit. Employees really think safety efforts are OK as long as the cost is not too high, or as long as it is not THEIR operation that is affected. Safety goals are set and all employees work toward their achievement. There are no detailed safety goals other than very general statements. Safety is an integral part of the training that all employees receive. There is no specific training on safety management processes and safety is barely mentioned in the existing training courses. Errors are understood as unintentional, but willful violations are not tolerated. Errors are treated unevenly and “suitable punishment” depends on the manager involved. Employees know and agree on what is acceptable and unacceptable behavior. The treatment of errors is inconsistent. The organization takes safety initiatives that go beyond strict regulatory requirements. The organization waits for the regulator to make a safety requirement mandatory before it commits any effort to new safety initiatives. Table 18. Typical signs of safety culture.

How Can You Tell If Your Organization Has a Strong Safety Culture? Accurately assessing the strength of the safety culture within an airport organization is a dif- ficult task, but it provides invaluable information to senior managers on the need for enhance- ment. It should be done on a periodic basis. Safety culture evaluations can be (a) simple and internal or (b) complex and independent. The level of effort depends on the degree of accuracy required and on the desired depth of information. There are several methods for evaluating safety culture within an organization and a multi- tude of guides on the subject. Four examples are presented: • Intuitive method • Checklist • Internal survey • External audit Intuitive Method We know what the culture of our airport is. We do not always ask ourselves, but if we stop and think, we can easily determine whether our organization has a strong or a weak safety culture. However, this intuitive method is not very objective, especially if we are part of the problem. It also relies on our perception, and if communication within the organization is an issue, our per- ception obviously will be biased. Nevertheless, asking whether our safety culture is strong or weak and why is a good initiative and demonstrates a willingness to identify and correct weak- nesses within the organization. Checklist Approach Using a checklist-based approach toward the five key characteristics of a strong safety culture can provide a more objective assessment. Table 19 contains checklist questions for each safety culture element. If you answer “no” to more than one question, or if the answer is not immedi- 94 Safety Management Systems for Airports Characteristics Question Informed Do employees really understand the risks associated with their job tasks and environment? Reporting Do employees report their safety concerns? Are employees willing and able to talk to management about their safety concerns? Do I, as a manager, really know what these concerns are? Do we share safety information throughout our organization? Just Do we accept that we should learn from errors, and not be predisposed to punish when mistakes happen? Are we clear about what constitutes an infraction that deserves some kind of punishment? Flexible Do employees apply procedures intelligently (or follow them blindly)? Learning Do we really ask ourselves and our employees: “is there a better way of doing what we do, from a safety perspective?” Table 19. Checklist approach for safety culture assessment.

ately clear, there is room for improvement. You could also use the examples of a strong safety culture provided in Table 18 as a basis for comparison. Internal Survey Internal surveys are an excellent tool for measuring the attitude of airport employees toward safety. When properly designed and executed, a survey can provide a quantitative score that relates to the strength of the safety culture in the organization. However, surveys are complex. Responses can be biased by the way the questions are asked. Respondents must feel free to respond accu- rately, and they must also feel that the questions do not unfairly target them. Asking the right ques- tions is an art best mastered by professionals. For example, the question “Do you feel comfortable sharing safety concerns with management?” puts the respondent on the spot, and the response provided may not accurately reflect reality. A more objective response may be obtained by ask- ing: “Do your co-workers feel comfortable sharing safety concerns with management?” Because of the complexity involved in designing the questionnaire, to get the right and true answers, it is recommended to have professional assistance to develop a survey that provides effective feedback. Table 20 provides an example of the type of statements that may be submitted in a safety cul- ture survey. It is based on actual surveys conducted in the U.S. and abroad. Using computers facilitates the gathering and analysis of data. However, paper surveys are quite adequate and often are able to target a wider audience. External Audit External audits usually are conducted by experts through a combination of questionnaires, interviews, and on-the-job observations. This is the most objective and accurate way of evaluat- ing the strength of an organization’s safety culture. Several firms are available to conduct such audits. In some cases, it is possible to solicit the help of like-minded organizations that are known to have a strong safety culture to conduct a comparative evaluation. One of the advantages of this approach is that it fosters the mutual exchange of safety information and healthy competi- tion between like-minded organizations. Promoting and Enhancing Safety Culture The question remains: How do I promote and improve the safety culture within my own organization? Culture is equivalent to a set of shared values held by the employees, the management, and the airport organization in general. Improving culture therefore means changing these values. However, changing individual and organizational values is not easy. Indeed, attempting to act directly on values is most likely to be met with cynicism, resistance and, ultimately, failure. Changing values is a long process that can only be achieved by first changing practices. There- fore, safety culture promotion efforts should focus on altering practices, in combination with a demonstrable and visible change in management attitude and leadership. Establishing an effec- tive SMS will assist in this process, but it is not sufficient. We can distinguish two types of activities needed to promote and enhance safety culture: safety culture leadership and safety culture integration. Safety culture leadership aims to promote safety culture within each branch of an airport organization—e.g., operations, maintenance, engineer- ing, emergency, security, human resources, finance, and information technology. Safety culture integration seeks to break the silos that often exist within large organizations and that constitute an obstacle to the effective exchange of safety information and management of interfacial safety issues (which are some of the most prevalent safety concerns for an airport operation). There are many measures and activities that can help to strengthen safety culture. In practice, and for the purpose of this guidebook, we will consider the initiatives listed in Table 21. SMS Operation 95

Employee Empowerment Empowering employees means giving them the ability to influence their environment. Expe- rience with aviation and other industries has demonstrated clearly that empowering employees improves morale, productivity, and efficiency in all aspects of their work, not only with respect to safety. With respect to SMS, empowering employees will lead to their involvement in the develop- ment of SMS at the outset. This last point is important. Many organizations feel that it is more 96 Safety Management Systems for Airports Your position: Management Supervisor Non-supervisory operational or tech staff Non-supervisory admin staff Other _______________________________ Rate each statement by selecting or circling the corresponding level of agreement to what you typically experience on your job. 1 = Strongly Disagree, 2 = Disagree, 3 = Not sure, 4 = Agree, 5 = Strongly Agree Management and supervisors regularly promote safety. Management and supervisors visibly sponsor and encourage safety initiatives and practices, for example, by asking for, and being open to, suggestions from all staff on how to improve safety. 1 2 3 4 5 N/A My co-workers feel comfortable sharing safety concerns. We always deal with our safety concerns in a friendly manner and my co- workers don’t get upset if someone points out that something is not being done properly regarding the overall safety. 1 2 3 4 5 N/A My co-workers receive enough training to do their jobs safely. The training that we receive makes us feel safe when we are doing our jobs. In addition, we received indoctrination training on safety immediately after we were hired. 1 2 3 4 5 N/A My Department’s vision and mission for safety are clear. We all know and understand where management stands when it comes to safety, and what it is trying to gain. 1 2 3 4 5 N/A My co-workers receive feedback from reports, suggestions, and concerns on airport safety. Any time that we make a report or suggestion, or present an idea on how to improve safety, somebody gets back to us on what is going to be done about it, even if nothing will be done. 1 2 3 4 5 N/A My co-workers are informed of the lessons learned from safety reviews and investigations. We are always informed of the conclusions of accident and incident investigations so that we can learn from them. 1 2 3 4 5 N/A Airport safety issues are effectively communicated between departments. All information about safety issues is passed on to other departments, so that all are aware of them, regardless of which department experienced them. 1 2 3 4 5 N/A My co-workers respond positively when they receive safety reminders. 1 2 3 4 5 N/A Unsafe conditions that cannot be immediately corrected are brought to the attention of management, or those who can do something about them. 1 2 3 4 5 N/A When we notice an unsafe situation/procedure that we cannot correct, we inform the appropriate person to resolve it. Table 20. Example survey on safety culture.

efficient to develop SMS and then market it to employees; however, this is less effective. Getting employees involved from the start saves time because it leads to an early “buy-in” and minimizes the risk of later resistance to change. Some initiatives that could be considered when fostering employee empowerment include the following: • Form a committee with broad vertical and horizontal representation to help define the cor- porate policy (which still needs to be finalized, endorsed, signed, and promoted by the senior executive), help define the non-punitive reporting policy and processes, develop corporate safety targets, etc. • Ensure broad representation on the team(s) responsible for analyzing safety reports and pro- posing mitigation control actions. • Get representatives from the major groups involved in the development of risk control action plans. • Be responsive to employees’ suggestions and ensure that they get feedback and recognition from supervisors and managers for their safety ideas and initiatives. Demonstrated Management Leadership The influence of management’s attitude over the entire organizational culture often is grossly underestimated. Without effective and visible leadership from the top, the SMS will be nothing but a nice binder on a shelf. Leadership is demonstrated through highly visible actions that confirm to the employees that management is really committed to safety and to all aspects of the SMS. How this is done depends on the type and style of leadership. There is no “cookbook” recipe, but the following are exam- ples of initiatives that can be considered, modified, and customized to assist airport managers in promoting and integrating a strong safety culture within the organization. Make Sure the Resources are Available to Achieve the Goals. The old saying of “do more with less” is not effective and sends the wrong message. If safety goals and programs are estab- lished, resources must be there to support them. Experience shows that the return on safety investments is well worth the initial cost. Attend Safety Meetings. Senior managers should take a genuine interest in safety meetings and should attend them, at all levels. Clearly, senior managers cannot always be present at all safety meetings throughout a large organization, but their presence at some will send a strong message to employees that they care. However, token presence (such as protocol-opening by uninterested managers) should be avoided. Similarly, ceremonial attendance (i.e., special provi- sions made because the “big boss” is coming to the meeting) reduces the effectiveness of this par- ticipation. Ideally, attendance by senior managers should not be subject to any special provision. Walk About. Managers often are perceived by employees as decision makers who conduct the show from behind their desk and do not really know what is happening on the “shop floor.” SMS Operation 97 Safety culture leadership Safety culture integration Employees empowerment Demonstrated management leadership Incentive programs Non-punitive reporting Communication and marketing Integrated training Organizational performance measurement Special events Partnering Table 21. Improving safety culture. Safety culture starts at the top!

One easy way to break this perception is for senior managers to take periodic walks around the airside operations areas. This should not be restricted to the operations manager or others for whom this type of presence is expected, but should also involve all other members of the man- agement team. “Walk abouts” are a great way to find out what is really happening. Asking ques- tions and discussing issues with the operational staff at their place of work conveys a great sense of care and commitment. However, beware of “ceremonial” tours or inspections by senior man- agers, which are announced and turned into a special event, for which employees may have to prepare to be on their best behavior. If safety issues are brought up during such tours, ensure that feedback is provided on what management intends to do about it, and that the feedback reaches the concerned employees. Communication with Employees. In periodic addresses to the staff, in writing or verbally, the senior manager should include safety and safety targets as a prominent item. This should be system- atic, constructive, and positive. This systematic inclusion of safety in senior manager communica- tions should extend to management meetings, airport operations committee meetings, and the like. Incentive Programs Safety culture is very much based on the concept that good behavior should be encouraged as much as or even more frequently than bad behavior is punished. Incentive programs are one way to encourage good behavior. Incentive programs can take several forms, including praise, recognition, or even monetary rewards. The precise nature of your incentive program depends very much on the type of culture and size of your organization. Not all the following suggestions will work for every organization. Most will need to be adapted to suit each airport’s “personality.” Safety Employee of the Month. Under this type of program, one or more employees are rec- ognized every month (or other frequency) for their ideas, suggestions, or contributions to safety within the organization. The reward can range from having the employees’ names published on the intranet or public billboard system, to having employee photos displayed in the airport or in the airport’s newsletter, magazine, or other suitable medium, to monetary rewards or gift cer- tificates. This program can be enhanced further by having employees nominate candidates with justification and involving a selection committee composed of a reasonable cross-section of employees from all the airport’s sections and departments. Safety Team of the Month. This initiative is similar to the preceding one but focuses on teams rather than individuals, reinforcing the concept of teamwork. It promotes the idea that teams that work together win. Competition. Competitions can be organized around a safety theme. As with the previous cases, these can be individual or team competitions, for example: • Safety logo design competition • Safety poster design competition • Problem solving competitions • Best article on safety, with the winning article to be published in a prominent magazine or newspaper 98 Safety Management Systems for Airports Care should be exercised in developing incentive programs that focus on lowering accident or incident statistics, because this can lead to underreporting.

Non-Punitive Safety Reporting Non-punitive reporting is a key element of SMS and is discussed in Section 6.4 of this guide- book. A detailed explanation is not repeated here, but it is important to understand that this ele- ment is potentially one of the greatest “killers” of a strong safety culture. Building employee confidence and trust in a system that encourages reporting of even their own mistakes, without fear of reprisal, takes time and unfaltering efforts. Destroying this trust takes 1 minute. A properly designed safety suggestion program can also be incorporated into the reporting system. It is important that the airport provide feedback for each suggestion submitted. Communication and Marketing Some communication and marketing initiatives can be aimed specifically at integrating safety culture across the entire organization. As with the other initiatives previously mentioned, the following examples need to be adjusted to fit the size and characteristics of each airport. Safety Newsletter. Safety newsletters published on a regular basis are a great way of promot- ing safety issues across the organization. They also provide a means of informing external stake- holders, which further enhances the integration of safety cultures. Safety Page. Many airports have a magazine published monthly or quarterly, or have access to another type of trade publication through which they can publish articles and information. One idea is to establish a “safety column,” where safety information is discussed, new safety ini- tiatives are presented, and winners of incentive programs are reported. Newspaper and Media. When significant safety programs or projects are initiated, media infor- mation focusing on the airport’s effort is an effective way to develop employee pride in the project. Safety Posters. Posters are a passive training method used to remind employees of a hazard, precaution, or idea (see Figure 12). Posters must be current and have a message applicable to the audience. Change them frequently so they don’t become part of the décor. For staff members who have access to computers, a brief safety message on the airport intranet homepage may be more effective than posters. Establish a “Safety Promotion Team.” Creating a team of representatives from several levels and sections can greatly enhance not only the integration of subcultures but also the effectiveness of the safety promotion program. School Involvement. In some small communities, where the airport occupies a prominent place in the economy, getting schools involved through, for example, essay competitions, airport visits, or other activities can enhance the sense of community among employees (who may work in different departments but whose children all attend the same school). SMS Operation 99 Example of a non-punitive reporting system failure: In an airport that prided itself on its program to implement non-punitive report- ing, one employee immediately self-reported after making an honest mistake in the operations area. For reasons that are complex, but unimportant given the perception that ensued, the employee was fired. Regardless of the real reason for the firing, the perception among other employees resulted in a dramatic reduction in the reporting of safety hazards.

Integrated Training Training should be recognized as a great potential safety culture integrator. Many traditional training programs focus on functional groups or levels. For example, there may be a leadership course for managers, a safety course for duty managers, or something similar. Strictly functional or single-level courses tend to reinforce divisions between groups within the organization. An integrated course brings together managers and staff from various departments and can help break down the barriers. Even when the course is predominantly focused on one functional area, everyone benefits from understanding what others do. Experience has shown that training is a very effective way of integrating subcultures within an organization. Safety Performance Measurement There are many possible safety performance indicators, and they are all useful in evaluating the success of the airport SMS. However, some performance indicators are especially helpful in integrating safety subcultures across the organization. To be effective, such performance indica- tors should be organizationwide and publicized. They should instill pride in the organization’s operation. They can also be compared with similar organizations or industry averages in an effort to promote healthy competition. For example, the following indicators, when normalized against a reasonable timeframe, could be considered positive safety culture integrators: • Number of incidents • Percentage of incidents considered serious (over the last month, for example) • Number of employee suggestions that have resulted in concrete safety improvements • Number of outstanding safety action items • Percent of strategic safety activities completed (in the current year) • Organizationwide safety audit score Special Events Special events focused on safety, when they are attended by people across different depart- ments and levels, can greatly enhance mutual cooperation and safety culture integration. Note 100 Safety Management Systems for Airports Figure 12. Safety posters (courtesy of Civil Aviation Authority of Singapore).

that airport service providers (airlines, fuel providers, FBOs, catering, commissionaires, etc.) should also be considered key potential participants. There are many types of events that can be organized or attended by the airport staff, for example: • Safety conferences and workshops (note that hosting such a conference at or near your air- port greatly enhances the promotion and integration benefits). • Safety campaigns, such as an “annual FOD walk,” recruiting airport employees to volunteer to participate walking the full length of the runway removing FOD. Such events can be fol- lowed by a staff luncheon or other event. • Safety-sponsored family days. Partnering It is essential to the success of airport planning as well as to its SMS to establish the philoso- phy and practice of continuously involving and consulting with the airport stakeholders. With- out proper and regular consultation with the FAA, airport tenants, and service providers, airport plans may be flawed. Not only do they know best how they work and what is needed for a safe and efficient operation, but it is likely that there is a wealth of expertise available within their own workforce. Partnership in planning should exploit all the knowledge, experience, and ideas from all stakeholders(32). A further benefit is the cooperation and good relationships that can be formed by communication and consultation. The airport operator normally will lead and direct the consultation process, which should include aircraft operators, ground handlers, and those contractors providing basic aircraft ser- vices such as catering, aircraft cleaning, and fueling. Where appropriate, the FAA and ATC should be involved. It is important that representation be at a suitably senior level to ensure sound input and decision making. It is recognized that a direct lack of coordination among key airport functions is an important factor in accidents and incidents. Long-term and sustainable improvements in airport safety can be achieved only through the collective commitment and joint efforts of all airport stakeholders. Partnering with other safety-related organizations(32) and affiliates will demonstrate a public commitment by leadership. Enlist the support of your target audiences where possible. Involve associations or representatives of your target audiences to disseminate information or, better still, as campaign partners. This can give your campaign greater credibility. You can identify partners who not only share your commitment but who can also share the resources needed for the campaign. It is important to understand and acknowledge the func- tions, priorities, and strengths and weakness of your partners. Be aware of cultural differences when operating across borders, and establish channels and forums for exchanging information and ideas regularly. Be clear who is taking responsibility for what activities and that the decisions taken are understood by all. Possible partners may include the following: • Airport tenants and service providers • The FAA SMS Operation 101 Partnering with stakeholders makes it easier to communicate the rationale for decisions and, ultimately, gain acceptance by those who will be affected by them. For example, when developing SOPs affecting the ramp area, it would be a mistake if the airport did not consult with the stakeholders having activities at the ramp.

• Aviation industry associations • State and local government • Other airports • Labor unions • Local schools and colleges • Institutes • Other units of the airport organization • Media 102 Safety Management Systems for Airports Do not rely on getting media coverage to promote your campaign because this cannot be guaranteed. 6.3 Cascading Meetings “Cascading meetings” is a technique that allows for a more dynamic communication environ- ment that will inform employees and increase engagement by providing a clearer line of sight between their day-to-day efforts and safety issues being discussed at the airport. With cascading meetings, communications are passed down through the hierarchy in a consistent manner, and all employees have a chance to be heard as they discuss the operations and changes taking place. The objective of cascading meetings is to improve communication within the airport organ- ization. It should be a two-way process, with feedback from lower levels going all the way to the top. Discussion topics may include any safety-related subject, for example: • The airport’s vision, mission, values, and principles • SMS processes • Continuous improvement actions • SOP • Safety objectives and performance indicators • Specific safety issues and lessons learned • Safety promotion Cascading involves each manager sitting down with his/her immediate team for a series of meetings. These meetings should enable everyone at the airport to understand and become aware of the discussion topic. Suppose the airport needs to discuss its vision and values to strengthen its safety culture. The basic concept is to cascade level by level throughout all departments until every staff member understands and is committed to the ideology of the airport. In this case, the effort is normally annual or periodic extending over a number of years. Leading a Cascading Meeting The managers should lead the meetings with their teams. Using a facilitator may not be effective. In the example previously described, it is important for team members to hear about the airport’s ideology from their direct leaders, who should be committed to the airport’s policies and goals. The leader’s purpose in these meetings is to promote discussion among team members. The leader should stay out of the discussion as much as possible after the initial explanation. Talk only as necessary to keep the team members talking. When using an outside facilitator to lead cascading meetings, make sure you have a skilled person that is trusted by the employees.

The leader should not give the impression that the airport’s vision, values, and principles are being rammed down employees’ throats. Commitment will come only after employees have vol- untarily accepted those principles following open and frank discussions. Each meeting leader should explain, give examples, and discuss what the airport’s ideology means to him/her; how- ever, the leader should not engage in a long tirade about the ideology should be adopted. The Cascading Process Cascading is a top-down, bottom-up discussion process that progresses through the organi- zation one level at a time. The first series of discussions is between top managers and their next level of managers. As shown schematically in Figure 13, the Executive Director meets with the heads of departments, then additional meetings are held between each department head and the head of each section within the specific department, and so on. At the end of each series of discussions, the safety issues in the airport are passed down to the next level for discussion. Proposed changes and unanswered questions will go up until they are resolved or answered. Attendees at one series of discussions will become leaders of the next series. The actual number and length of the meetings should be determined by the local organizational structure and situation. Cascade meetings may be used within a specific department or section of the airport. For example, when discussing safety objectives of the operations department, discussion will take place among staff within the operations department. Rationale and Pitfalls Most airports have a range of communication processes in place for cascading information via meetings, email, newsletters, intranet, message boards, and so forth. But the emphasis needs to be on two-way communication. It is assumed that corporate messages are received, under- stood, and supported, but all too often, the true message gets lost in transit. Not everyone finds time to read the newsletters and emails. SMS Operation 103 Cascading meetings are most effective for organizations like large hubs. Smaller airports will benefit little from this technique; how- ever, they should still hold meetings to discuss their safety issues. 1st Level 2nd Level Superv. A33 Superv. A32 Head Section A3 Head Section A2 Section B3 Executive Director Head Dept B Head Dept C Head Dept A Head Section A1 Section B2 Head Section B1 Head Section C3 Head Section C2 Head Section C1 Superv. A31 Superv. A23 Superv. A22 Superv. A21 Superv. A13 Superv. A12 Superv. A11 B23 B22 Superv. B21 B13 B12 Superv. B11 B33 B32 Superv. B31 Superv. C33 Superv. C32 Superv. C31 Superv. C23 Superv. C22 Superv. C21 Superv. C13 Superv. C12 Superv. C11 Employees etc. Figure 13. Cascade meetings process.

Posting information on an intranet and giving employees responsibility for keeping up to date is one of the latest forms of communication. While fast and flexible, accessing the intranet may be low on the list of priorities for busy people. Cascade meetings can be effective, but even the best managers do not always put the message over in the most timely or persuasive way; not everyone checks that staff have understood, and few check that individual staff members know what the communication means to them and to their role. Figure 14 depicts two cascade meeting processes. In the first situation the communication runs smoothly from the upper to the lower levels of the organization. In the second one, somewhere along the flow process, the information is truncated and not effectively passed to lower levels. 104 Safety Management Systems for Airports Effective Not Effective Figure 14. Possible outcomes of the cascading meeting process. Cascading meetings are not always effective. Some of the reasons include the following: • Managers may resist holding the meetings • The issues are poorly delivered and lack effectiveness • Understanding of the issues is not consistent • Feedback process is sanitized • Effectiveness of the process is not evaluated Possible means for safety reporting include the following: • Hardcopy forms and drop-boxes available at various airport locations • An intranet and/or Internet SMS webpage with safety reporting capability • An airport safety phone hotline • Managers and supervisors meetings • Daily briefings, tasking, and debriefings • Intranet/Internet messages 6.4 Safety Reporting With SMS and a strong safety culture to support it, airport employees gain self-confidence to report hazards, incidents, accidents, and errors. There are additional benefits generated with SMS reporting including the following: • Workers are willing to share their errors and experiences • They become more knowledgeable regarding SMS as a whole • People become motivated to learn new lessons and are more comfortable and helpful when implementing new approaches to improve safety • They are aware of what is considered acceptable and unacceptable behavior

From the implementation of a good SMS flows a solid hazard reporting system(33) with at least the following characteristics: • Voluntary, impartial, confidential, and non-punitive (so as to generate trust in the individu- als providing information). Legal counsel is appropriate to check how applicable laws may impact confidential and/or non-punitive reporting systems. • Easy to be reached by any airport employee or stakeholder (auxiliary service companies or air- lines, passengers, and other airport users) to report a hazard • Able to ensure that recommendations resulting from the investigation are available to the air- port operator for information and resolution purposes • Presented in oral or written form. In all cases, reporting must be documented • Able to safeguard confidentiality • Adequate for documenting reported hazards and prompt evaluation of the safety issue • Able to include a response to the reporting party as to the action taken, and its dissemination to the organization, if the airport operator deems it necessary • Managed by the SMS Manager, who is operationally responsible for monitoring the status of hazards identified • Engenders sufficient trust that people are willing to report their errors and experience • Encourages (sometimes, rewards) people to provide safety-related information A good way to get the reporting system working is by raising employee awareness of the pur- pose of the system. An example of a safety reporting form is depicted in Table 22. SMS Operation 105 Reporting systems are one of the most significant ways of obtaining safety infor- mation. You cannot fix something if you do not know what is wrong. However, many systems fail because of the lack of adequate and timely feedback to per- sonnel or follow-up actions. A non-punitive reporting system may encourage people to report events that might otherwise not get reported. This would allow you to get more information about hazards in your operation before an accident happens. Setting up a non-punitive reporting system requires a lot of planning and careful design. The purpose is to encourage reporting by removing fear of punishment. However, that does not mean that people can get away with negligent behavior or with willfully breaking rules. This can sometimes lead to situations where the administration of discipline can be perceived as inconsistent. It is important that everyone understands when punitive actions will or will not be taken. Moreover, the airport has no authority over other organizations (e.g., tenants). Airport contracts and lease agreements may need to have specific clauses to address such a policy before it can be established by the airport operator.

106 Safety Management Systems for Airports VOLUNTARY SAFETY REPORTING FORM This form should be used to report any airport hazard that has caused or could cause an accident or incident. Send to the SMS Manager as soon as possible after the hazard has been identified or an incident/accident has occurred. 1 PERSONAL DETAILS (person reporting) Name: (optional) Position: (optional) Contact info: (optional) 2 INCIDENT/HAZARD DETAILS Date: Time: AM/PM Shift: Day: Afternoon: Night: Location: Brief Description of Incident/Hazard: (attach diagrams, sketches, or photographs, if available) Are there witnesses?: YES: NO: Names of witnesses:(optional) Type of Incident/Hazard Health and/or Safety Property Damage Environmental Near Miss Other Level of Injury (If applicable) No Injury First Aid Medical Treatment (Doctor) Hospital Inpatient Fatal Brief description of injury/damage Confidentiality Commitment You can submit the form anonymously (if you so chose) by omitting relevant details. If you do provide your name, it will only be used by the SMS Manager to enhance the understanding of the event with follow-up actions should that be required; and, under no circumstances, will your identity be disclosed to any person or organization without your express permission. At large and medium airports, safety reporting may require a more formal procedure because the organization may have many layers and sections, making communication more difficult to achieve. At small airports, particularly those for general aviation, communication tends to be more effective and is normally performed on a daily basis. A less formal procedure is recommended for small airports. However, even for general aviation airports, it is important to keep track of what and when a safety issue was reported, and which actions were taken to solve or mitigate the risks involved. A simple spreadsheet should be sufficient for this purpose. Table 22. Example of safety reporting form.

6.5 Accident and Incident Investigation Accident investigation is a key component of any SMS. Thousands of accidents occur each day in the United States, some of which could be prevented by identifying the underlying causes of the accident and implementing appropriate corrective actions(34). An accident investigation SMS Operation 107 SAFETY REPORT PROCESSING FORM (To be completed by SMS Manager) Report Number: Date report was received: Assessed Level of Risk: Referred to: - Appropriate Dept Manager: Yes No, Name/Dept……….……………… - Safety Committee: Yes No, Name/Organization………………… Entered into Safety Risk Database: Yes No If yes, specify the date. Treatment actions required: Person responsible: Completion date estimated: Feedback: Is reporter known? Yes, advised of outcome on: Date: No, event and action communicated on: Date: Through: Safety bulletin Safety meeting Ramp Safety Committee minutes Other Safety event (describe): Person completing form: ________________________ Signature: Date: __________ Manager/Supervisor: ________________________ Signature: Date: __________ Table 22. (Continued). The Freedom of Information Act (FOIA) is applicable to information controlled by the United States government. Each state has its own open records legislation that governs documents at the state and local (cities, counties, school districts) levels. Such legislation may be applicable to your airport. In this case, you must include a note in your Confidentiality Commitment stating that the airport may have a legal obligation to provide all information that is available, including the reporter’s identity, if this information is requested and it is available in the airport’s records.

Fortunately, since accidents in the aviation industry are rare, you can get a great deal of knowledge and experience by obtaining reports of significant events from external organizations(35), such as regional or international accident or incident reports (e.g., National Transportation Safety Board [NTSB], ICAO, Transportation Safety Board of Canada, UK Air Accidents Investigation Branch). program is a safety management tool used to identify the contributing factors and causes of an accident in order to eliminate or mitigate these factors and ensure that similar accidents are not repeated. A qualified investigator is a person that has received training on how to conduct investigations and determine root causes of incidents and accidents. When an accident or serious incident occurs, qualified investigators should be available to conduct the investigation with the follow- ing purposes: • Improve understanding of the events leading up to the accident/incident • Identify root causes and assess actual hazards • Provide recommendations to mitigate risks • Communicate lessons learned from the investigation In many instances, the investigation of minor incidents, such as near misses at the ramp, may yield evidence of systemic hazards. For maximum effectiveness, the investigation should focus on determining root causes rather than identifying persons to discipline. It will be necessary to provide appropriate training on topics such as human factors, investi- gation procedures, or interview techniques to some of the appointed personnel. However, you do not need to provide this training to all staff within the organization; you might want to focus on training lead investigators first, for example. Section 6.6 provides additional information on internal safety investigations. Accident Causes An accident is defined as an unplanned, undesired event that affects the completion of a task. At its lowest level, an accident occurs when a person or an object is exposed to an unsafe level of energy or hazardous material. There are many forms of harmful energy, including acoustic, chemical, electrical, kinetic (impact), mechanical, potential (stored), radiant, and thermal. Acci- 108 Safety Management Systems for Airports The causes of an accident/incident can often be found by asking Who + What + Where + When + How + Why for each key event in the accident/incident until you know why the accident happened. Separate facts from theory and opinion As much as possible, look for underlying causes—avoid jumping to conclusions. Analyze the factors surrounding the accident.

dents are complex, sometimes involving 10 or more events that can be considered contributing factors. Most accidents have three different cause levels: root, indirect, and direct. The direct cause of the accident would be the energy or hazardous material. The direct cause usually is attributable to unsafe conditions and/or unsafe actions. The unsafe conditions and actions are considered to be indirect causes or symptoms. The indirect causes are typically a result of root causes, which may include an inappropriate procedure for the work or task, adverse environmental factors, personal judgment, and/or poor management decisions. The relation- ship between root, indirect, and direct causes is shown in Figure 15. Most accidents are preventable by simply eliminating one or more of the causes. Proper acci- dent investigations are crucial for determining what happened and how and why it happened. The goal of accident investigation and reporting is to minimize the chance or reoccurrence and in turn to prevent more severe accidents in the future. Types of Events All incidents have the potential to become injury-related accidents and should be investigated. The following terms explain the different types of events that should be investigated to deter- mine the incident’s contributing factors: • Accident—An accident is an undesired event that results in personal injury or property damage. • Incident—An incident is an unplanned, undesired event that adversely affects completion of a task. • Near Miss—Near misses describe incidents where no property was damaged and no personal injury was sustained, but given a slight shift in time or position, damage and/or injury easily could have occurred. Accident and incident reports help identify hazards and other contributing factors that may have been overlooked or slipped through the system. They also identify hazards that have the potential to become serious accidents. SMS Operation 109 Management Safety Policy & Decisions, Personal Factors, Standard Procedure, Environmental Factors Unsafe Condition Unplanned Release of Energy and/or Hazardous Material ACCIDENT Personal Injury Property Damage Unsafe Act ROOT CAUSES INDIRECT CAUSES (SYMPTOMS) DIRECT CAUSES Figure 15. Accident causes.

Investigation and analysis follow reporting, hazard identification, or high risk concern. Usu- ally the investigation is conducted by a team/person with experience in the area of concern. Investigation Analysis Techniques There are three techniques commonly used to help understand the underlying causes of inci- dents: the Causation Model, the Fishbone Analysis, and the “5 Whys.” Causation Model The basic causes of incidents can be grouped into the five categories shown in Figure 16: task, materials, environment, personnel, and management. All possible causes in each of the cate- gories should be investigated when using this technique. Task. Looking at the causes associated with a task involves exploring the procedure that was being followed when the accident or incident took place. Questions such as “Is the work proce- dure safe?” and “Were the tools and materials used appropriate for the existing procedure?” should be asked and the answers documented. Materials. The materials used should be investigated to determine if any possible causes or contributing factors can be associated with materials and/or equipment. Questions about equip- ment failure, possible failure mechanism, design, maintenance, hazardous materials, and so on should be asked, and answers should be documented. Environment. Environmental conditions have been known to contribute to unsafe condi- tions and are often a contributing factor in an accident. The actual conditions at the time of the accident and any sudden changes in the environment that could have occurred near the time of the accident should be the focus of the investigation. Personnel. The condition of the personnel (both mental and physical) must be considered as part of this analysis. Again, the objective is not to place blame on an individual, but rather it is to get to the root of the problem and all possible angles should be explored. Questions about employee training, frequency of the work, employee health status (both physical and mental), and so on should be asked. Management. Management personnel and safety policies should be considered during an accident investigation. Ultimately, managers are decision makers and they have a legal respon- sibility to promote safety in the workplace. Some of the direct and indirect causes of an accident are due to failures within a management system. Questions concerning safety policy and proce- dures, inspection schedules, employee supervision and training should be addressed. The causation model is a good tool for determining the causes associated with a specific acci- dent or incident. It is important to note that, when using this model, each time a question reveals an unsafe condition that particular question should be followed up by another question that addresses why the unsafe condition was allowed to exist. Fishbone Analysis This analysis is used in more complex investigations and is particularly useful when many experts are gathered. Typically, each will have his or her own particular expertise and concerns, and the fishbone analysis focuses all participants in the investigation to defined aspects of the operation. An example outline of the technique is shown in Figure 17. The group will include the elements determined from the brainstorm session. In this example, all participants are asked to focus on issues related to defined topics—equip- ment, people, materials, and programs/procedures. Each is discussed in turn, and concerns for 110 Safety Management Systems for Airports Personnel Environment MaterialsTask Management Figure 16. Causation model.

SMS Operation 111 Equipment Materials People Program Procedures Monitor failure Operational constraint Under-engineered Off specification Degradation Below specification Lack of maintenance Lack of commitment No training experience No supervision Responsibility unclear No policy No management system Not addressed in procedure Not covered in maintenance program U nde sirable Effe ct Figure 17. Fishbone investigation process. Runway incursion by construction truck Driver did not follow escort vehicle Driver did not follow escort vehicle Driver did not follow airside rules Driver did not follow airside rules Driver did not know about the airside rules Driver did not know about the airside rules Driver did not understand training provided Driver does not understand English Driver did not understand training provided caused by caused by caused by caused by caused by Figure 18. “5 Whys” investigation process. each are written on the diagram. Other defined topics may be added at the discretion of the investigating team. At the end of the analysis, the resultant fishbone will look somewhat like the example shown. The concerns identified are then investigated in detail to get to the root causes of the issue. It can be seen clearly that this technique will allow for multiple root causes, ranging from mechan- ical to human and organizational factors. “5 Whys” The following is a simple example of the questioning technique used in the “5 Whys.” In this example, depicted in Figure 18, a driver that was hired by a contractor to conduct a construction job on the airside failed to follow the directions from the escort vehicle. The incident resulted in a runway incursion because the driver was not able to speak or understand English; therefore,

the training provided was ineffective. The escort person was not aware of that. The important point is that the investigation discusses issues that would preclude repetition of the problem. Typically, once the issues in the fishbone have been identified, the “5 Whys” technique is applied to each factor in an attempt to find the root causes of each. These techniques allow a skilled team to focus on different aspects of an issue so that all the underlying causes can be addressed. It ensures that no one person is able to dominate the discussion with preconceived ideas, and it also allows both hard engineering issues and human factors issues to be drawn out equally in discussions. It is not normal for people to want to make mistakes, and so these techniques try to ask why people found themselves in the position to make the error in the first place. Getting the Facts The goal of conducting an accident or incident investigation is to gather information that can be analyzed that will lead to the improvement of the airport safety policy and reduce the num- ber of accidents that occur. The following four steps are necessary for creating such a system: 1. Gather Information 2. Analyze Information 3. Draw Conclusions 4. Make Recommendations It is important to gather information from all available sources, which may include, but are not limited to the following: • Physical Evidence—Physical evidence is defined as “tangible evidence” (e.g., aircraft damage, picture, document, or visible injury) that is in some way related to the accident/incident that gave rise to the case. Examples include the equipment or materials left at the scene of the acci- dent, the position of injured persons or other objects, the weather conditions, and documen- tation of the involved persons or conditions. All physical evidence should be examined and documented. • Eyewitness Reports and Interviews—It is important to gather information from any eyewit- ness reports and, if possible, conduct interviews with all parties involved. Interviews should be conducted from a “fact finding” rather than a “fault finding” perspective. • Background Information—All policies, procedures, inspection reports, maintenance reports, and other relevant documents should be considered, and appropriate information should be acquired as part of the investigation. Once all of the information is collected and one of the analysis techniques above is used, the team of investigators should work to draw conclusions. When drawing conclusions, it is impor- tant to answer “why” the accident occurred. It is also important to support and document the root causes with evidence and reasoning. Drawing conclusions based on the gathered information may lead to gaps in the original analysis. If gaps are discovered, the existing information should be re-examined. Sometimes, additional information may need to be gathered to bridge these gaps. The final step is to draft written recommendations for corrective actions to take, and if rele- vant, to improve safety policies and procedures. This step is extremely important to reduce and prevent accidents of a similar nature from occurring in the future. The written recommenda- tions should be as specific as possible and address all root causes and contributing factors. Man- agement should address all recommendations from accident and incident reports by updating safety policy and procedures if necessary. 112 Safety Management Systems for Airports

An example accident/incident investigation form containing helpful information to be gathered is presented in Table 23. In the last portion of this form, the investigator may describe some risk control options. The arrow indicates the priority that should be adopted for these actions. 6.6 SMS and Internal Safety Assessments Continuous improvement is one of the core concepts addressed by an SMS. To help airports ver- ify that management efforts are focused in the right direction and that the objective of continuous SMS Operation 113 Accident/Incident Investigation Form Date: Investigator: Airport: Incident form number: Date of incident: Time of incident: Injured person: Type of injury: Property damage: Damage to aircraft by apron equipment Damage to/by moving aircraft Damage to property/equip. Equip. to equip. damage Equip. to facilities damage Damage from wildlife Other (describe) Witnesses: Brief description of incident: Immediate/short-term actions to prevent recurrence: How long has the person conducting the task been working prior to the incident/injury occurring? How long had the person conducting the task been working on the task? Is this task part of the normal duties for the person conducting the task? Yes No Had the person performing the task been instructed/trained in how to perform it? Yes No What were you doing in the time prior to the incident/injury? What were other factors involved? If other, please specify. Environment Equipment Hazardous Substance Other Table 23. Example of accident/incident investigation form. (continued on next page)

improvement is being achieved, SMS incorporates a set of specific tools to measure improve- ment over time. Some of the most valuable of these tools are the SMS self-assessment and inter- nal safety assessments, which are part of the Safety Assurance pillar of SMS. The SMS self-assessment process also offers a unique mechanism that “checks and balances” the SMS to ensure that its pillars and elements are working effectively. Internal safety assessments help evaluate how effectively individual units of the airport (e.g., maintenance, ARFF, dispatch) are 114 Safety Management Systems for Airports Accident/Incident Investigation Form ENVIRONMENT Was there an acceptable standard of safe conduct in play? If no, provide details: Yes No Was there good visibility? If no, provide details: Yes No Was there adequate lighting? If no, provide details: Yes No Was there adequate means of access? Yes No What was the precipitation condition? Dry Rain Snow Hail Drizzle Other, specify: How was the Surface condition? Dry Ice Snow Wet Slush Standing water EQUIPMENT Did any equipment/vehicle contribute to the incident? If yes, provide details: Description of Equipment: Type: Make: Yes No Did the design/quality of the equipment/work area contribute to the incident? If yes, provide details: Yes No Did the location/position of the equipment contribute to the incident? If yes, provide details: Yes No Had the hazard/risk been recognized previously? (e.g., Pilot Report, incident report, hazard report, etc.) Yes No Were employees informed/aware of the hazard/risk? If yes, provide details: Yes No Was the equipment in good working order? If no, provide details: Yes No Date equipment was last serviced: Was the correct equipment being used for the task? If no, provide details: Yes No Was the equipment being used correctly? If no, provide details: Yes No Table 23. (Continued).

working relative to safety and if they have the right resources to achieve their safety goals. When agreed between the parties, the airport may want to conduct safety assessments on the operations of airport stakeholders (e.g., tenants) to ensure they are operating in line with the airport rules and regulations, that they have staff that is adequately trained, and that their resources (e.g., equipment) are appropriate and in good condition to work safely in the airport environment. These assessment processes are internally initiated examinations of the performance, activ- ities, systems, and processes in place within the airport related to SMS and safety. In general, an SMS assessment is performed on an annual basis. Safety assessments normally focus on areas that are most deficient; however, every airport unit should be assessed regularly (e.g., every other year). The goal of an assessment is to have an open and transparent “second look” at the processes and resources to identify areas where improvements may be needed. It is a tool to evaluate how SMS Operation 115 Table 23. (Continued). Accident/Incident Investigation Form PROCEDURES/SIGNAGE Was there appropriate safety signage displayed? Yes No Were there SOPs for the task? Yes No Had employee/s been instructed/trained in the SOPs? Yes No Had employee/s been deemed competent and understood the SOPs? Yes No Were safe working systems observed? (e.g., isolation procedures) Yes No Was the workload considered excessive? If yes, provide details: Yes No Was the task repetitive? If yes, provide details: Yes No HAZARDOUS SUBSTANCES Was an MSDS (Material Safety Data Sheet) available? Yes No Were the storage/handling/disposal of the substance(s) adequate? If no, provide details: Yes No TRAINING/SUPERVISION Was the employee/s physically capable of doing the task? (e.g., good health, no disability, recovering from illness). If no, provide details: Yes No Was there frequent supervisor/employee/s contact to discuss/review hazards and job procedures? (e.g., safety meetings, daily briefings). If no, provide details: Yes No ANY OTHER FACTORS INVOLVED? Please explain: Investigator’s comments and observations: (continued on next page)

effectively the airport is working toward improving safety. These evaluations will include (a) review- ing and evaluating the actions taken to ensure that they are producing the desired effects and (b) monitoring business activities and their impact on safety to determine where efforts should be directed. Audit Versus Assessment You may hear the terms assessment and audit used interchangeably. However, while it is true that the processes and activities associated with each are very similar, in the context of SMS, they are technically different. Audit focuses on compliance and conformance to a given standard and is based on factual verification of non-conformance, usually associated with prescriptive regu- lations. Assessment focuses on the effectiveness and efficiency of an SMS and collects data to make judgments on its performance. Table 24 provides examples to help differentiate between assessment and audit. In some countries, SMS has been adopted and promulgated as a performance-based regula- tion. This means that, while the regulator is seeking to achieve a certain outcome, the means of achieving this objective is, for the most part, left to the regulated party (i.e., the airport). In the context of SMS, assessment is then the most suitable term to define this process. (Note that much of the international literature concerning SMS calls an assessment an internal audit or self-audit.) Assessment Principles Inspections, evaluations, and the like are guided by a series of principles or characteristics that verify that the outcomes have achieved their objectives. SMS and safety assessments are no different. The following are some of the key principles that need to be observed when perform- ing an SMS or an internal safety assessment. 116 Safety Management Systems for Airports Accident/Incident Investigation Form Risk Control Options Action Required By Whom By When Avoidance—does the operation need to take place? Or do you have to do the task? Transfer—is there another way you can manage the operation or do the task? Control—can you engineer a way to make the operation/task safer? e.g., eliminate the hazard, substitute operation, use engineering and/or procedural controls. Date and feedback provided to person reporting the injury/incident: Investigation Completed By: Print Name: Sign: //Date Completed:Position: Table 23. (Continued).

Internally Initiated Traditionally, airports and other aviation organizations have relied on periodic certification inspections by the FAA to identify non-compliance and to obtain recommendations on correc- tive actions. SMS steers away from this approach and calls for airports to take the initiative for periodic assessments to review all operational processes of SMS and safety. These internal assess- ments evaluate the performance of the processes and the resources available to determine whether and how they are achieving their objectives. Based on these assessments, corrective measures can be taken, if improvements are needed. Comprehensive To ensure that the results and observations of the assessment are accurate and representative, an effort should be made to include all processes, activities, departments, resources, and levels of personnel affected by the scope of the SMS. Depending on the size of the airport, the com- plexity of the operations, and the availability of resources, the scope of an assessment may vary. The assessment may cover the whole spectrum of an SMS in a single exercise, or it could be sched- uled in such a way that different areas or units are targeted independently. If the latter approach better suits your airport, make sure that, at the end of each cycle, all areas and aspects of SMS have been covered. Independent and Objective Dealing with the everyday activities of airport operations can create diverse and, sometimes, conflicting priorities. It is important that, in this environment, you focus on safety and that the processes put in place to support the SMS remain relevant and practical. SMS Operation 117 Requirement Measurement Outcome Audit 139.305 Paved areas …The pavement edges must not exceed 3 inches difference in elevation between abutting pavement sections and between pavement and abutting areas. The auditor/inspector would physically measure difference. If the difference is more than 3 inches: Non-Compliant; if it is 3 inches or less: Compliant. Assessment An airport should have a safety policy in place Is the policy documented? Is it effective? Is it communicated? Is it periodically reviewed? Is it signed by the AE? etc. Based on the judgment of the assessment team, this requirement is evaluated on whether it satisfies the principles of the SMS or not, and if it is effective for the size and complexity of the airport. If improvements are necessary, the assessment team will provide recommendations. Table 24. Examples of audit and assessment.

A fresh look from a party that is not immersed in and directly affected by day-to-day activities would provide the objectivity necessary to assess your SMS and safety performance. Some larger airports might have an audit function/department within their organizational structure. If this is your case, you can take advantage of this support to perform the assessment. Other large air- ports that do not have an auditing department may consider performing cross-departmental assessments under the direction of the SMS Manager or another experienced facilitator. For medium and small airports, it may be a challenge to find the necessary level of objectivity and independence in house. The logical choice would then be to seek outside help. An approach that might suit your airport is to make a bilateral agreement with other similar airports in the region to perform each other’s SMS assessments. Of course, airports large and small could also secure the services of an outside independent firm to perform their SMS assessments if none of the approaches works for them. Frequency The frequency and scheduling of SMS and internal safety assessments should be related to the risks identified with specific activities or functional departments and the results of previous assessments. In general, such assessments are performed annually or biannually. Unscheduled or ad hoc assessments should take place when significant changes or events occur, such as a major organizational restructure or an accident. Assessment Methodology This section provides a high-level overview of how an assessment is carried out and the steps necessary to accomplish one successfully. Every airport or external organization will set up an assessment process that best serves its needs, but in general, it will basically follow the steps depicted in Figure 19. 118 Safety Management Systems for Airports Having an external person/team perform the assessment does not violate the principle of an internally initiated examination since the initiative to review SMS performance comes from the airport and not from an external agency. The assessment methodology and the tasks described in this section are appropri- ate for large and medium airports. The checklists and tables are applicable to smaller airports as well; however, the methodology can be less formal. A large airport may have a team to conduct the assessment, whereas small airports will likely have only one person performing the assessment. Pre-Assessment Tasks Audits and assessments are demanding exercises. They are labor intensive and can be very dis- ruptive to the normal operation of the airport/department being assessed if not properly planned. Preparation before the site visit will mitigate any undue stress on those being assessed and greatly enhance the possibility of successfully achieving the assessment objectives.

Pre-assessment tasks may include the definition of the assessment team, preparation of an assessment plan, selection or development of an assessment checklist, notifying the unit to be assessed, organizing and scheduling the visit, requesting and reviewing key documentation, iden- tifying key staff and scheduling interviews, and other such activities. Define the Assessment Tool SMS evaluations are performance-based, and this means that both the process and the end result are important to achieve the safety objectives; therefore, different airports may have dif- ferent processes to achieve their safety goals. While the principles and elements of SMS do not change, the structure and way in which these elements are arranged to provide a framework may vary. The same is true with the airport units and the procedures and resources they use to carry out their activities. Whether an SMS regulatory framework is in place or not, the purpose of an SMS assessment is to ensure that all the elements that define an SMS and their associated processes are in place, functioning effectively, documented, being practiced, and support management objectives. The idea is to review all operational processes of SMS and assess them against the pillars and elements of the framework. Once that has been done, you can determine whether the processes are achiev- ing their objectives and identify where improvements may be needed. For internal safety assessments, the process should be tailored to the airport unit subject to the assessment. A checklist to assess the ARFF unit is different from the one used for maintenance or an airport tenant. SMS Operation 119 Pre-Assessment Tasks On-site Assessment Tasks Post-Assessment Tasks Define assesssment tool to be utilized Entry Meeting Measure observations Define assessment scope Site Tour Conduct interviews Develop assessment plan On-site document review Request and review the airport’s documentation Record observations Prepare assessment report Exit Meeting Select the assessment team Data collection Figure 19. Generic assessment protocol.

Determine Assessment Scope Depending on how you approach this exercise, the scope of the assessment may vary widely. At this stage, you have to define the parameters that will govern the assessment. The scope defi- nition should cover the following at a minimum: • Geographic extent of the assessment (e.g., Apron C, whole airside, Parking Garage B) • Business unit being assessed • Time period • Assessment topics (e.g., assessment of the SRM process, training, equipment) • Level and depth of detail of the assessment Select Assessment Team The scope of the assessment will determine the number and qualifications of the personnel assigned as assessment team members. It is not necessary that all team members have the same qualifications, but it is important that, as a team, they are able to cover all the technical expertise and experience needed to perform the job effectively and efficiently. For example, the team conducting an assessment of the airport ARFF unit should have at least one member with experience in ARFF. In addition, it is recom- mended that team members are free of any potential conflict of interest. At the very least, the assessment team as a whole should have audit or assessment experience, technical expertise in the functional area being assessed, and knowledge and experience with SMS. When the team includes more than one member, a team leader should be appointed as the single point of contact for the team. Develop Assessment Plan The assessment plan is the master document that will lay out the activities, requirements, and details of the assessment process. It should include the following at a minimum: • An introduction defining the purpose and the scope of the assessment • Tentative dates and locations of the assessment • A description of the assessment methodology and approach • A detailed schedule of planned activities • Members of the team, including their roles and responsibilities • Logistic requirements This plan should be developed and presented to those being assessed in advance of the assess- ment itself. The planning and pre-arranged logistics will ensure that the normally limited time available for the on-site visit is used efficiently. Request and Review Documents The assessment process should begin well in advance of setting foot in the facilities of the department being assessed. Significant information can be obtained through the review of exist- ing documentation before the visit, such as information on existing processes and practices and what is, or more important, what is not documented. It will also help, in the case of a stakeholder 120 Safety Management Systems for Airports If your airport has an internal audit group or function, you should consider their support, either to help you develop an assessment protocol and/or to assist with data collection and analysis.

SMS Operation 121 The key to effective interviewing is to spend more time listening than talking. Your goal is not to fill out a form but to elicit essential information that will help your SMS assessment. assessment, to familiarize the team with the operations and the organizational structure of the unit or department and assist in selecting key people to interview. The following are some exam- ples of typical documents that would be helpful to review: • SMS policy statement • Certificates/permits/approvals • Hazard identification records • Procedures and practices • Past assessment/incident reports • SMS documentation such as the SMS Manual, hazard log, accident investigations • Organization charts • Performance indicators and trend analysis • Training records (for internal safety assessments only) • Equipment maintenance records (for internal safety assessments only) On-Site Assessment Tasks All tasks performed during this phase will help validate processes and procedures included in the documentation reviewed, establish a rapport with personnel from the department being assessed, and provide a deeper insight into the airport/department being assessed. Entry Meeting This is meant to be a brief introductory meeting to further expand on the details presented in the assessment plan, clarify specific points about the methodology and the scope of the process, and confirm all logistic requirements. Data Collection Site Tour. The first task the assessment team should perform once on-site is a physical tour of the facilities. This allows for a firsthand view of the operation, a direct observation of the prac- tices used by staff in the field, and the general condition of the infrastructure, equipment, and work conditions available. It will also help identify potential interviewees and assist the assess- ment team in starting to set up a list of sample questions. Interviews. Interviews provide a fertile and dynamic setting for the gathering of information. Unlike the document review or the site tour, which can provide only a snapshot of the informa- tion presented, interviews allow for follow-up questions and interaction to better clarify issues. As with every other skill, performing interviews effectively requires training and practice. The following tips provide an overview of the key activities associated with this task: • Identify the SMS and safety elements to be addressed • Identify potential issues • Record notes in bullet form, concentrating on key facts • Keep a record of items to follow up on later • Ask open-ended questions • Conduct the interview in a location where the interviewee will be comfortable (e.g., their place of work)

On-Site Documentation Review. As the assessment team gathers information, other doc- umentation will emerge that was either unknown at the time of the pre-assessment review or impractical to be made available at that time. The assessment team should collect and review this information as it becomes accessible. The type of documentation that might emerge could include the following: • Internal documentation detailing management and other responsibilities • Control mechanisms • Information management • Training and awareness programs and records • Permits, approvals, licenses, and exemptions • Contracts and specifications • Maintenance records • Specific operating procedures Record Observations As the assessment progresses, the information collected must be recorded and organized in a manner that is relevant to management and easy to cross reference with the assessment check- list. An effective guideline to ensure that the observations stated are credible and clear should at least include the following steps: • Describe the situation (SETTING): The setting is a description of the circumstances through which the information was gathered. • Identify the requirement (CONDITION EXPECTED): The condition expected is the assess- ment team’s expectations of the item being assessed. • Describe objective evidence (CONDITION FOUND): The condition found is the actual observation and must be stated in a factual manner that is clear and precise yet conveys the full extent of the situation including instances when best practices were demonstrated. It must be supported with the appropriate data (e.g., document or interview reference). • Cite the reference to the standard (REQUIREMENT): The requirement is the airport policy, best management practice, the airport’s rules and regulations, or other citation reference. This must be included in every observation. 122 Safety Management Systems for Airports The assessment team members should be encouraged to review and organize their notes as soon as possible after completing an interview or site visit. It is easy to lose track of insights and observations after only a few days. Exit Meeting The exit meeting provides a summary of what took place during the assessment. Its purpose is to conclude the activities of the assessment, present airport or department managers with a sum- mary of the principal observations gathered during the assessment, and provide an opportunity for management to discuss and clarify any potential discrepancies. Post-Assessment Tasks This phase of the assessment seeks to formalize the process into a deliverable. Depending on the initial scope of the assessment, this phase will conclude the assessment of the airport or targeted unit.

Measure Observations and Provide Assessment With all the information on hand, it is now time to provide a more accurate and detailed judg- ment of the assessment, supported by the observations made throughout the assessment process. Regardless of the tools used during the exercise, the purpose of an assessment is to validate mea- sures put in place to achieve successful and safe operations, and to determine their effectiveness and efficiency. In other words, the assessment has to provide answers to the following questions: • Existence: Have the measures developed by management been implemented, and to what degree are those measures being used and applied? • Efficiency: Are the measures providing the best possible results/benefits for the level of effort/resources exerted to support them? • Effectiveness: Do those measures support the objectives set up by management with regard to SMS and safety? While most of the answers to these questions are judgment based and rely heavily on the assessment team’s experience and knowledge of SMS and safety, there are tools available to sup- port less experienced assessors. An example of a simple tool for SMS assessment is one that breaks down the SMS framework by pillars, elements, and expectations. A random scale can be used to allow for comparison of different elements. An evaluation of independent expectations defines the scoring for each element. The scores for all elements are then added to score each pil- lar, then all pillar scores are added to provide an overall SMS score. The use of such a tool is described in Annex B of this guidebook. Develop Assessment Report The assessment report is the final task of the process and documents the overall assessment. It also identifies the strengths and weaknesses of the airport/department’s practices, procedures, and available resources in support of the SMS and safety objectives. The report does not need to be formal. It should indicate to the airport management and Accountable Executive those deficiencies identified during the assessment process so that cor- rective actions can be taken. This document may include the following: • An executive summary of the observations • Date of assessment and assessment period • Team members • Objectives and scope • Assessment expectations/criteria • Summary of assessment process (i.e., sampling and assessment plan) • Details of observations • Results of the assessment • Recommendations for corrective actions • A list of documents reviewed The final assessment report usually is prepared by the team leader, with input from the assess- ment team. SMS Assessments SMS Assessment Tables SMS assessments are similar to the gap analysis process, in that they both examine and evalu- ate the SMS elements. But whereas gap analysis is done before the SMS is in place, to check what is available, what is missing, and what needs to be adapted, the SMS assessment looks at the in- place SMS elements to determine how effectively they are functioning and to rate them for per- SMS Operation 123

formance. Moreover, the assessment may look only at individual elements of the SMS or even individual units of the airport to check how well they are performing their SMS roles and tasks. SMS assessment tables are available in Annex A. The assessment tables are designed to organ- ize and consolidate the information and observations collected during an SMS assessment. How to Use The worksheets are a series of tables that contain all of the expectations associated with each SMS pillar and element. There is space for the assessment team to record information references, score, and observations (justification for the given score). The tables shown in Annex A are organized as follows: • The first column contains SMS expectations • The second column is for describing the references—the source of observations or informa- tion collected during the document review or interviews • The third column is for the score assigned to each expectation—the scoring methodology is described in the following SMS Scoring Methodology section • The fourth column is for the observations/information collected by the assessment team that justify the assigned score References During the assessment, team members should collect as much information as possible to use as references to support their observations, including the name, position, and department of the person being interviewed; the observation location and time; and the document title, publica- tion date, and reference number. If the expectations worksheets are going to be part of the final deliverable to the client, a complete reference may not appear in the final version to protect the privacy of individuals. However, this information should be available to the assessment team during the scoring process and for future reference, if required. Scoring Scoring should be conducted by all members of the assessment team according to the method- ology outlined below. Pillar and element scoring should be done after all of the team member’s observations have been recorded on the worksheet. Observations All members of the assessment team should transfer their observations from their notebooks to the worksheets and score each expectation. There need only be one working copy of this document, which is passed between team members. This may be done at the end of each day of the site visit. SMS Scoring Methodology One possible alternative to quantify the assessment is presented in this section. Once all of the observations have been recorded, the team should collectively score the SMS elements. There should be a consensus on the score assigned to each element. In the event that there is a disagree- ment, the team leader will make the final decision. The following criteria should be used. 1. Score Expectations Expectations are given a score (see no. 2, Score Elements) based on the information col- lected during assessment to remove subjectivity. The score may have one or more comments associated with it that provide justification and context. Expectations may be scored by individual team members. Another team member may override the initial score if the information required to justify a change is provided. Team members should come to a consensus on the score assigned to each expectation. 124 Safety Management Systems for Airports

2. Score Elements The assigned score is not based on a mathematical average of the expectations scores; rather, expectations scores serve as a guide for pillar and element scoring. Sub-elements and elements are given a score of 0 through 4 as follows: “0” is given when none of the expectations under the element are met (comments/justifi- cation required) “1” is given when some of the expectations under the element are met (comments/justifi- cation required) “2” is given when all expectations under the element are met (no comment required) “3” is given when all of the expectations are met or exceeded (comments/justification required) “3+” may be assigned if the assessment team feels that the organizational unit has done an exceptional job, meeting or exceeding all of the expectations under this element, and deserves extra mention (comments/justification required) “4” is given in the event that the organization exhibits a best practice for this element (rare, extremely subjective, and may only be assigned by an SMS expert with particular industry experience [comments/justification required]) Add the sub-element scores to assign element scores, as required. Again, the score is not based on a mathematical average; the sub-element scores serve as a guide for the element scores. Elements can only be assigned whole numbers; no decimals. All team members should agree on the element scores before assigning pillar scores. Element scores should be recorded on the scoring table presented in Annex C. 3. Add to Score SMS Pillars Pillars are scored last, following a similar process to element scoring. The assigned score is not based on a mathematical average of the element scores. Element scoring serves as a guide for pillar scoring. Pillars are given a score of 0 through 4, following the same criteria used for the sub-element scores. Pillars can only be assigned whole numbers. All team members should agree on the final pillar scores. Pillar scores should be recorded on the scoring table presented in Annex C. Internal Safety Assessments SMS is a systematic approach to managing safety risks within an organization. SMS achieves this objective by establishing a series of processes and procedures that, once developed and implemented, will help an organization identify and address potential risks in relevant areas. One of the most effective processes at your disposal for this purpose is the internal safety assessment (some organizations prefer the terminology internal safety audit). Since we are trying to take an inward look at airport safety performance, we will use the term internal safety assessment even when it is applied to an airport tenant. Essentially, this process helps departmental and divisional leaders be self-critical and, ultimately, will help make their department/division as safe as possible. When these safety assessments are performed in a different organization working at the airport, there needs to be an agreement between the airport and the stakeholder or clause in the lease contract because there is currently no regulatory basis for the procedure. SMS Operation 125

The internal safety assessment process can be used by both senior managers and department/ division directors and managers to ensure that the area for which they are responsible is as safe as possible and/or to identify specific deficiencies. Airports are very complex environments. They differ greatly depending on the size and type of operation. Their risks and “safety status” or “safety health” will also vary depending on things such as their safety culture, level of maturity of the SMS, organizational structure, and manage- ment style; however, there are common functional areas that should be targeted during an inter- nal safety assessment. There are many different theoretical and conceptual models that provide different methods for performing self-assessments/audits. In this section, key functional areas are presented that affect safety. Managers and directors should consider these when evaluating their departments and divisions for safety. Ideally, the airport should develop specific checklists to assess each of these areas. These checklists can be continuously improved as more safety assessments are performed on a reg- ular basis. Each subsection presented is not meant to provide an exhaustive list of questions that can be asked when performing an internal self-assessment. They are meant to provide gen- eral guidance for department and division managers and directors who may perform these assessments. Safety Management System This area concerns your department/division performance with respect to SMS. This part of the assessment can be completed by using the tools provided in this section that concern SMS assessment for the whole organization. Some questions to ask in addition to those provided in the SMS assessment subsection are as follows: • Has my department/division established the appropriate SMS processes? • How often does my department/division use these processes? • Have I assessed all the regulatory standards and regulations that affect me? • Has my department/division established objectives in line with those of the organization? Staff This area concerns the people who work within the organizational unit being assessed. These are the human resources that do the work and ensure the unit accomplishes what it needs to do. There are three major functional areas you need to assess to determine safety: competency, job satisfaction, and safety culture. Some questions you can ask yourself are: • Have all my employees received the training they need? Is this training adequate? • What is the turnover in my department/division? • Do employees use/follow operating procedures? • How many grievances have been filed in a given period of time? • Do employees understand the organizationwide safety initiatives? • Do they understand their safety roles in the unit and in the airport organization? • Are they motivated to do their jobs, and do they care about safety? Assets This area concerns the equipment and materials used by the unit. The availability and status of equipment and material play a very important role in safety. The equipment may serve as a control for preventing an accident or incident; however, if it lacks proper design, calibration, 126 Safety Management Systems for Airports

maintenance, or use, the equipment may fail and be the cause of an accident or incident. Ques- tions to ask include the following: • Is your staff appropriately trained in the use of the equipment/tools they are provided? • Are all of your assets being properly maintained? How do you know? • Do you have standards to determine the required equipment specifications? • Can your people use your assets while wearing PPE? • Is the quantity of material and equipment appropriate for the size of your operations? • How do you deal with equipment breakdown? Do you have a backup? Environment This area deals with the working environment in which your department/division operates. Temperature, lighting, space allocation, outdoors versus indoors, and so on can be considered. Essentially, you want to ensure that the environment does not lead to accidents. The following are questions to consider: • Does it ever get too hot or too cold? Has this led to human error or equipment failure? • Are rain/snow storms considered in your procedures? • Is there adequate lighting? • Do your people always have enough space to do their work safely? • Do you have specific procedures for unfavorable weather conditions (e.g., strong winds, low visibility, rain/snow, lightning, winter operations)? Organization The unit organization and its place in the airport organizational structure are very important. This organization provides, among other things, the overarching policies, programs, and systems to which you must subscribe, and controls the allocation of resources your department/division receives. The unit must operate within this larger organization effectively to achieve a high level of safety. Some questions to ask are as follows: • Have there been any major organizational changes that may affect your department/division? • Does your department/division have the resources it needs (financial, human, asset)? • Do you have access to higher levels of management to elevate safety issues? • Do you have a positive and cooperative relationship with the regulatory authorities? Occupational Safety and Health This area deals with conventional occupational safety and health matters. While SMS focuses mainly on airport activities, departmental/divisional managers or directors must concern them- selves with safety as a whole. This subject is well documented and regulated worldwide, and many assessment tools exist. Some questions to consider are as follows: • Does my department/division have adequate PPE? Is it used properly? • Has my department/division received all the necessary training related to occupational safety and health? • Do personnel practice lockout-tagout? • Do personnel perform regular housekeeping inspections? Airport Tenants and Contractors This area deals with airport tenants and contractors and their effect on airport safety. Air- port stakeholders play a large role in the operations of every airport and, as such, must be taken into account when assessing the safety of any department/division. Again, there needs to be an SMS Operation 127

agreement between the airport and the stakeholder to permit a safety assessment of the stake- holder unit at the airport. Some questions to consider might include the following: • Are there provisions in leases/operational agreements to ensure the management of safety issues? • Do stakeholders follow airport rules, regulations, and procedures? • Do they keep safety records? Are they complete, accurate, and used to track progress? How well are they performing? • Do they participate in airport safety meetings? Do they have their own safety meetings? • Do their service providers have specific safety training? • Do they report accidents and incidents? • Are their employees aware of how to report safety issues? • Do they have appropriate resources to operate? • Is their equipment well maintained? Interfaces In this context, an interface is the boundary between two (or more) of the functional areas where they interact. Some of these interfaces are readily apparent in some of the previous ques- tions, for example: • Can your staff use your assets while wearing PPE? This is an example of the interface between occupational safety and health, assets, and people. • Do the procedures that they use apply to all weather conditions? • Is their training program aligned with the department needs? • Do their current schedules provide for supervision during all shift work? 6.7 Measuring SMS Performance—Trend Analysis Importance of Trend Analysis The causal factors of accidents and incidents, and the effectiveness of corrective actions at an airport can be fully understood and evaluated only if their frequency and distribution are exam- ined in terms of type of event, location, and conditions. Trend analysis is one leg of this analytic triangle. It is used for hazard surveillance and monitoring, forecasting, program evaluation, pol- icy analysis, and the investigation of potential causal relationships between risk factors and out- comes. Trend analysis is used for the following objectives: • To identify the overall pattern of change in a safety performance indicator over time (increase or decrease, rate of change) • To compare one time period with another (effectiveness of operations before versus after a risk control action or the implementation of new regulations) • To compare different airport areas or seasonal differences (level of safety for Apron A and Apron B; accident rates in summer versus winter) • To compare two or more groups (trained versus untrained, different service providers) • To make future projections (monitor progress toward a safety objective; provide an estimate of the rate of future occurrence) What Is Trend Analysis? Trend analysis looks for changes in safety levels over a given time period (e.g., the last 12 months). The safety level is usually measured using key performance indicators selected by the airport. 128 Safety Management Systems for Airports

The objective of trend analysis is to • Determine the “safety health” state of the airport, • Identify trends in safety levels, and • Identify needs and determine actions required to maintain and/or improve safety. Management could have set a goal to reduce ramp incidents by 20%. This statement is appropriate at the organizational level, but before ramp oper- ations can act on it in a meaningful way, it needs to identify at least two things: (1) the baseline (i.e., how many incidents are occurring now) and (2) which activities are having an effect on apron incidents (passenger bridge, service equipment-aircraft, vehicle-vehicle, etc.). This knowledge comes from trend analysis. If you do not have the necessary data, set up a method (as part of your reporting system) that will allow you to collect data relevant to those activities. Once you start collecting the data, you will know how many incidents are occurring. You can then set a baseline against which you can compare future performance. You should be careful when using the raw number of accidents or incidents to verify trends. The number of undesirable events is related to the number of operations and a drop in the num- ber of incidents may be a consequence of a decrease in activity level. You may prefer to use acci- dent rates instead of the number of accidents. An accident rate is the number of accidents divided by a fixed number of operations over a period (e.g., 10,000 operations in 1 year). A decrease in the rate of accidents is a clear and reliable picture of safety improvements at your airport. Analysis of the data collected should allow you to identify which activities have the most impact in the incident count. This information should help you focus on the major problems and develop action plans to reduce them. At the same time, it will allow you to track whether these plans are effective. Assume that the data collected show that, after 6 months, bridge-aircraft incidents add up to eight events. After analysis and investigation, you decide that implementation of a stricter train- ing program and spot checks should improve airline employees’ skills and compliance with the rules, thus reducing the number of bridge-aircraft incidents. Six months later, when you do your next review, you should be able to see if the number of incidents has gone up or down. If the number of incidents has not decreased, additional actions will be required (e.g., intensifying supervision and enforcement of SOPs) to mitigate the likelihood of more incidents. Measurements must focus on factors that are related to overall safety objectives. Most impor- tant, measurements must be related to the most significant risk contributors. Although per- formance measurements include incident statistics, they are primarily intended to be proactive (i.e., identify problems before an accident occurs). SMS Operation 129 If the airport wants to measure the level of safety at the ramp, a simple safety performance indicator in this case may be the number of accidents that have occurred on the ramp in any given month. Checking if the number of accidents is increasing or decreasing over the months is trend analysis. Analyze trends to determine if things are getting better, getting worse, or staying the same.

Data Considerations For SMS, most trend analysis data are related to the key safety performance indicators selected for monitoring. The airport needs to make sure the data quality objectives are met. Trend analy- sis requires strict monitoring protocols. If the airport wants to determine the trends for apron accidents, it should make sure reliable data are gathered every month over a significant period (e.g., 3 to 5 years). It is essential to identify the audience and the type of analysis or presentation appropriate for that audience. For example, if it is necessary to report the trends to raise safety awareness at the ramp, the audience will be every person working on the ramp. In this case, the message should be very simple. Determining the cause of a trend is more difficult than determining the trend, but it is the crit- ical element for defining effective corrective actions. To identify causal factors for certain trends, it is necessary to consider all the exogenous parameters that can influence those trends (volume of traffic, environmental conditions, time of day, etc.). The following are some important issues to consider when developing a trend analysis: • Consistent data quality—Trend analysis assumes that the same or equivalent methods and protocols are used for all the monitoring. • Time frame and number of samples—5 years of monthly data for accident and incident trend analysis; for step trends, at least 2 years of monthly data before and after a major change (e.g., new SOP, change in personnel, application of a corrective action, change in organization). • Seasonality—Parameters that vary naturally in different seasons of the year may require spe- cial statistics (e.g., certain types of birds can be more frequent in specific months of the year; apron accidents are more prone to occur under low visibility conditions). 130 Safety Management Systems for Airports Some representative performance indicators can be as follows: • Number of airside vehicle operation infractions per month • Number of FOD reports • Number of bird strikes • Number of runway incursions • Percentage of employees with basic SMS training Collecting information on the number of violations should be done carefully to avoid bias. If you do not have enforcement officers on the ramp, the numbers may actually go down, even when more incidents occur. For larger airports, performance indicators may be related to specific areas of the airport, for example: • Number of airside vehicle operations infractions per month on Apron C • Number of runway incursions at a specific “hot spot”

• Statistical significance of a trend—It is common to observe upward or downward trends that simply occur by chance (see an example in Figure 22). This is particularly frequent for per- formance measurements over small periods or associated with low incidence events (e.g., number of runway incursions). The best way to check if the trend is real or is simply random variation is to set longer periods for evaluation to collect more data and use statistical tech- niques to check if the differences are statistically significant. Gathering Data After the airport safety objectives and goals are set, it is necessary to define the safety perfor- mance indicators that will be used to measure performance and check if the objectives are being met. Trend analysis is based on quantitative information collected for these performance indi- cators (e.g., number of incidents at the ramp, number of bird strikes). The airport operator who records each of these accidents will have a number for each month over a period of a few years. Other sources of data available for trend analysis are conclusions from accident/incident reports. The root causes identified in the investigations can provide valuable information on spe- cific safety issues that should be addressed by the airport. Data collection is a critical activity for trend analysis. It is recommended that a written proce- dure be established to define who will collect the data, the means for collection, specific proce- dures, and who will receive the information. Table 25 depicts an example of information on safety performance indicators over a 6-year period, and Table 26 shows an example of data gathered on the number of bird strikes in each month. Table 27 contains the number of job-related injuries at the ramp and the number of operations at the airport during 9 months. SMS Operation 131 Very small operators may not generate enough data to allow for the monitoring of any trends. In these cases, a possible alternative is to look at the industry as a whole to help identify possible trends. Reviews of accident reports, articles in trade magazines, discussions with industry groups, participation in industry associations, and other operators can provide useful data. Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 2003 0 1 2 0 3 0 2 2 1 3 1 2 17 2004 1 0 3 0 0 1 1 2 0 2 1 1 12 2005 0 0 1 0 2 0 0 0 1 0 1 0 5 2006 1 0 0 2 1 1 0 1 0 1 0 0 7 2007 0 2 0 1 2 0 2 0 1 0 1 1 10 2008 1 0 2 0 1 1 0 0 3 1 2 0 11 Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total 2003 3 0 5 4 1 2 7 1 2 0 3 1 29 2004 1 4 2 2 1 5 6 4 0 2 1 4 32 2005 2 0 1 1 0 2 4 1 2 0 2 1 16 2006 0 1 2 1 0 0 3 1 0 2 0 1 11 2007 1 0 0 1 0 1 2 0 0 1 1 1 8 2008 0 0 1 0 1 0 2 0 0 0 1 0 5 Table 25. Number of ramp accidents (example). Table 26. Number of bird strikes (example).

132 Safety Management Systems for Airports Month Total Number of People Injured Total Number of Aircraft Operations Rate of Injuries per 10,000 operations Jan 6 6648 9.03 Feb 5 5180 9.65 Mar 4 4895 8.17 Apr 3 3650 8.22 May 4 5055 7.91 Jun 5 6230 8.03 Jul 6 8350 7.19 Aug 7 10640 6.58 Sep 8 10910 7.33 Table 27. Number of job-related injuries at the ramp. Figure 20. Plotting for visual analysis (example). Trends for Safety Performance Indicators 29 32 16 11 8 5 17 12 5 7 10 11 0 5 10 15 20 25 30 35 2003 2004 2005 2006 2007 2008 Year N um be r o f O cc ur re nc es Ramp Accidents Bird Strikes Measuring Trends There are two methods to determine trends: visual and statistical. As shown in Figure 20, graphing or mapping data for people to see is the easiest way to communicate trends, especially to a non-technical crowd; however, this method does not allow one to “measure” that there is a trend or how big it is. Even when a statistical analysis is performed, it should start with the visual assessment of trends. Another example is depicted in Figure 21. In this example, the root causes of runway incur- sions by type of vehicle over a period of 1 year are counted. It can be noted that the operation of emergency/snow removal vehicles was the main activity associated with runway incursions, and the airport should take actions to provide additional training to those drivers. In addition, based on the high frequency of incidents associated with communication procedures, the airport may decide to provide additional training on radio communication, replace existing equipment, and establish procedures for escorting contractors. The statistical method, on the other hand, can identify hard-to-see trends and can give a num- ber that is defensible and repeatable; however, such methods can be difficult and challenging to apply. A statistical analysis is best performed by a qualified person.

SMS Operation 133 For most cases, a visual analysis with some very simple statistical measuring will be sufficient for evaluating most safety performance indicators used in airport SMS. Plotting and Smoothing Spreadsheet software like Microsoft® Excel can be used to plot information on safety perform- ance gathered by the airport. Usually, the information is plotted over the period that the data were collected, sometimes called time series. When evaluating plots, care must be exercised regarding the following issues: • People tend to focus on the extreme values and not on more subtle changes • Gradual trends are hard to detect by visual analysis • Seasonal variation and exogenous variables can mask trends in a parameter • Viewers can “see what they want to see” sometimes • Finding no trend may only mean the data were insufficient or the type of plot was inappropriate Using the example data for bird strikes in Table 26, the plot in Figure 22 can be generated. Obviously, it is very difficult to state any conclusions from this plot. However, by using the average number of bird strikes for the last 12 months instead of using the raw number of bird strikes in any given month, a trend may become more evident. Moving averages can be used to smooth out short-term fluctuations, thus highlighting longer- term trends or cycles. The threshold between short term and long term depends on the factor being analyzed, and the parameters of the moving average should be set accordingly. For the previous example, the average number of bird strikes for Jan 2003 is computed by averaging the results from Feb 2002 to Jan 2003. For Feb 2003, the value is the average from Mar 2002 to Feb 2003, and so on. Note that there are no data for the first 11 months simply because there is no information available to compute the average for the past 12 months. The resulting Figure 21. Runway incursions in 2007 (example). Root Causes of Runway Incursions by Vehicle Drivers in 2007 0 1 2 3 4 5 6 7 8 9 Operation of emergency/snow removal vehicles Unfamiliarity with airport (contractor) Lack of proper phraseology or equipment Communication equipment failure Driver was distracted N um be r o f O cc ur re nc es

134 Safety Management Systems for Airports Number of Bird Strikes per Month 0 0.5 1 1.5 2 2.5 3 3.5 Ja n-0 3 Ma y-0 3 Se p-0 3 Ja n-0 4 Ma y-0 4 Se p-0 4 Ja n-0 5 Ma y-0 5 Se p-0 5 Ja n-0 6 Ma y-0 6 Se p-0 6 Ja n-0 7 Ma y-0 7 Se p-0 7 Ja n-0 8 Ma y-0 8 Se p-0 8 Month N um be r o f A cc id en ts Figure 22. Number of bird strikes per month. Figure 23. Bird strikes trend using a 12-month moving average. Average Number of Bird Strikes for Previous 12 Months 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 Ja n-0 3 Ma y-0 3 Se p-0 3 Ja n-0 4 Ma y-0 4 Se p-0 4 Ja n-0 5 Ma y-0 5 Se p-0 5 Ja n-0 6 Ma y-0 6 Se p-0 6 Ja n-0 7 Ma y-0 7 Se p-0 7 Ja n-0 8 Ma y-0 8 Se p-0 8 Month A ve ra ge N um be r o f B ird S tri ke s trend for bird strike data is depicted in Figure 23. In this case, the frequency of bird strikes was decreasing until the beginning of 2006, when it started to increase. Using Accident and Incident Rates The examples presented so far have used raw data only. However raw data can sometimes be misleading because the number of accidents and incidents tends to have a relationship with the volume of operations or the intensity of activities.

The example data given in Table 27 puts the problem in perspective and helps your under- standing. As noted in that table, the number of job-related injuries at the ramp dropped from January to May; and after June the numbers started to rise. The trend is shown in Figure 24. However, the volume of operations changed significantly during this period. One can expect to have a higher number of accidents if more operations are carried out at the airport. If, instead of raw numbers, the rate of accidents per 10,000 operations is used, a different trend can be observed. The rate can be calculated using the number of accidents in a given month and the number of aircraft operations for that same period, using the following equation: AccRate = TNAcc × 10,000/TNOps Where: AccRate is the rate of accidents per 10,000 operations TNAcc is the total number of accidents in a given period TNOps is the total number of aircraft operations during the same period For example, using the data from Table 27, in January: AccRate = 6 × 10,000/6,648 = 9.03 injuries per 10,000 operations The fourth column in Table 27 depicts the accidents rates for the example data provided. When plotting the accident rates, instead of the raw data, the trend shown in Figure 25 is observed; the rate is clearly decreasing. Trend Analysis Reports As a minimum, the following information should be reported for each trend analysis: • Display plots of the observed data over time • Comments in narrative form on the stability of the rates and approaches used to improve it • Report average percent change for periods when the rate is fairly constant • Interpret in narrative form the trend and how it relates to achieving the safety objectives of the airport SMS Operation 135 Number of Job-Related Injuries 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 Month N um be r O f A cc id en ts Figure 24. Trend for job-related injuries at the ramp.

136 Safety Management Systems for Airports Rate of Job-Related Injuries at the Ramp 6 7 8 9 10 1 2 3 4 5 6 7 8 9 Month In jur ies /10 ,00 0 o ps Figure 25. Rate of job-related injuries per 10,000 operations at the ramp. Figure 26. Monthly average of apron accidents. Average Number of Apron Accidents 1.17 0.83 1.83 1.50 0.50 1.67 4.00 1.17 0.67 0.83 1.331.33 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month N um be r o f A cc id en ts In addition, always attempt to identify any factors causing the trend. The analysis is more con- vincing if it demonstrates that apparent trends can be explained by plausible relationships with other factors. For example, if using the example data depicted in Table 25 and plotting the aver- age number of accidents on the apron for each month over a 6-year period, the bar chart depicted in Figure 26 can be developed. The figure suggests the number of accidents is higher for July. Causes could be related to the increase in operations, or to the frequency of low visibility conditions, or to both factors. 6.8 Safety Training and Education Your airport needs to establish and provide a training program to staff to maintain excellent safety levels. This may apply to general work functions and SMS functions. It may also apply to

contractors and service providers who need to be aware of at least a minimum level of airport SMS requirements and emergency procedures. Moreover, safety training and education are essential elements in creating a positive safety culture within the airport organization, which is vital to the operation of an effective SMS. All employees must have the skills and competencies necessary to perform their duties in an effective and safe manner. In addition to safety skills training, airport workers need to be aware of their SMS roles, safety responsibilities, and how they can cooperate to bring about a safety sys- tem that works. Some key players, like the SMS Manager, may need to develop their capacity to manage and run the SMS processes. Safety training should begin with the initial indoctrination of employees and continue through- out the duration of their employment. Specific safety management training should be provided for staff occupying positions with particular safety responsibilities. The training program should ensure that the safety policy and principles of the organization are understood and adhered to by all staff. According to AC 150/5200-37(1), safety training and education should consist of the following: • A documented process to identify training requirements • A validation process that measures the effectiveness of training • Initial (general safety) job-specific training • Recurrent safety training • Indoctrination and initial training incorporating SMS • Training that includes human factors and organizational factors Currently, training programs are administered by individual airports and safety training is focused on 14 CFR Part 139 requirements, which at this point does not address SMS. This sec- tion of the guidebook describes a systemic approach to safety training and suggests four levels of safety and SMS training programs to cover the needs of different staff levels and SMS functions in the airport organization. Systemic Approach to Safety Training Effective training does not just happen; it requires planning and management. Every airport training program should follow a Systems Approach to Training (SAT). The SAT process is depicted in Figure 27 and includes the activities described below. • Needs Analysis: Identify the jobs and the tasks associated with each position and determine the related knowledge and skills required to safely perform those tasks. Moreover, the safety risk management process and the SMS review will also help identify training needs. • Design: Define the training objectives and the methods by which training will be delivered, and design test items and methods to verify whether training objectives have been met. • Development: Establish the sequence and level in which the training topics will be presented, develop lesson plans, develop or assemble training manuals, gather all required training mate- rials, and identify instructors. • Instruction: Prepare instructors, deliver training, and obtain feedback (testing) of participants. • Program Evaluation: Measure the effectiveness of the training program through internal and external evaluation to validate the program and promote identification of areas where improvement might be indicated. Two types of evaluation should take place: — A post-training evaluation questionnaire given to the course participants immediately following the training. — A post-exercise verification of the training retention, conducted no less than 2 weeks after the training and no more than 90 days, through a brief interview with selected participants. SMS Operation 137

• Review: Based on the results obtained during the Program Evaluation phase, revisions and updates to the program should be made; • Documentation: All documentation generated during these processes is managed following the document control and management process. Training Levels Under the SMS framework, four types of safety training should be provided to personnel working at the airport: indoctrination training, job-specific training, SMS training for managers and supervisors, and SMS training for staff. Indoctrination Training Mandatory and recurrent SMS indoctrination training should be provided to all personnel performing duties at the airport with access to secured areas. This includes personnel from all organizations authorized to operate at the airport such as aircraft operators, fuel providers, cater- ing organizations, ground services companies, FBOs, enforcement agencies, and government organizations. SMS indoctrination training can be delivered in conjunction with the security identification display areas (SIDA) identification process and prior to the issuance of the access control card. This training delivery can be presented in a classroom setting and include one or more support- ing materials, such as pamphlets, introductory briefs, videos, or PowerPoint presentations. The safety module should include the basic topics given in Table 28 and should be designed for anyone working at the airport. 138 Safety Management Systems for Airports Needs Analysis Design Training Develop Training Instruction Program Evaluation Review Training Identify tasks associated with each job Determine knowledge and skills required to safely perform tasks Define delivery method Define training objectives Design test items and methods Define training sequence Develop lesson plans Prepare training materials Identify resources: instructors, training facilities, equip., etc. Prepare instructors Schedule and deliver training Test participants Perform evaluation Identify needs for improvement D oc um en ta tio n Safety risk management and safety reviews D oc um en ta tio n Figure 27. Systemic approach to safety training diagram.

Job-Specific Training Most categories of airport staff will require additional occupational health and safety training to ensure they can perform their duties in a safe manner. Part of this safety skills training is a statutory requirement and is contained within specific regulations. Other required skills will be identified in the airport’s job training needs analysis. Clearly, the specific types of training required for airport staff members working in airport areas will depend on the functions fulfilled by the individual. This program should be customized by the head of each airport department and should be fabricated for the specific needs of each employee. A suggested general program for this train- ing is described in Table 29. SMS Training for Managers and Supervisors It is essential that the airport management team understand the principles on which the SMS is based. Training should ensure that airport managers and supervisors be familiar with their roles, responsibilities, and accountability for safety. They should receive training that addresses the legal issues involved and their legal liabilities. Also, managers should know their SMS roles; how to set specific safety goals for their departments/sections; the fundamentals of reactive and proactive haz- ard identification and safety risk management processes; and how to identify, assess, prioritize, and treat risks in their area of responsibility. A suggested prerequisite for this training is SMS indoctri- nation because managers and supervisors should be aware of the SMS training their employees are receiving. Table 30 includes a basic training program with the topics that should be covered. SMS Operation 139 Item Description Prerequisites: None Duration: 30 min to 1 hour Schedule: Offered regularly, as required Intended for: All new airport employees and personnel from other organizations authorized to operate at the airport Topics: Safety policy and objectives, safety roles and responsibilities, how to report safety issues, familiarization with airport areas, rules and regulations, communication procedures, and general emergency procedures Testing: Quiz at the end of the session (pass/fail) Item Description Prerequisites: SMS indoctrination Duration: As required Location: On-the-job training (office, field, etc.) Schedule: To be completed within the first two weeks of employment Intended for: All new airport employees Topics: Training aimed at a specific work area: familiarization with the department, description of specific tasks, description of specific procedures, the importance of safety, main hazards and risks on the job, key safety procedures, specific emergency procedures of key safety personnel Testing: Overall evaluation by the instructor (pass/fail) Table 28. Training program for SMS indoctrination. Table 29. Job specific safety training program.

SMS Staff Training To ensure the effectiveness of the SMS program at your airport, those individuals with a direct role in the management of the program will supplement their skills through specific training pro- grams. They include the following: • SMS concepts • Safety risk management • Investigation and root cause analysis techniques • Reviews, inspections, and audit procedures and techniques • Data collection and database management • Trend analysis It is important that staff performing these tasks receive adequate training in specific methods and techniques. Depending on the depth of training required and the level of existing expert- ise in safety management within the organization, it may be necessary to obtain assistance from external specialists to provide this training. Table 31 depicts a general training program for this level. In addition to these four types of safety training, individuals who require key safety skills will need to receive up-to-date refresher training. The frequency should vary according to the degree of the risk, the use of the skills, the rate at which skills can be forgotten, and when any significant 140 Safety Management Systems for Airports Item Description Prerequisites: SMS indoctrination Duration: 1 ½ day Schedule: Offered as required Intended for: Managers and Supervisors Topics: SMS legal requirements and regulations; SMS roles and safety responsibilities; procedures for setting policies, objectives and goals; establishing safety performance indicators; safety communication; demonstration of commitment to the airport safety policy; developing SOPs; cascading meeting; how to manage safety risks including hazard identification, risk assessment, prioritization and treatment; management of change; safety culture and promotion; and continuous improvement. Testing: Quiz at the end of the course and completion of three hazard identifications and corresponding risk assessments (pass/fail) Item Description Prerequisites: SMS Training for Managers Duration: 5 days Schedule: To be completed during the first 6 weeks of employment Intended for: SMS staff Topics: Basic safety concepts; SMS pillars and elements; safety risk management; SMS planning, implementation and operation; investigation roles, techniques and procedures; interviewing and surveying techniques; data collection and database management techniques; safety records management; trend analysis Testing: Test (passing grade of 80%) Table 30. SMS training program for managers. Table 31. Training program for SMS staff.

Training Documentation Records of all training sessions, attendees, test results, and syllabus review and updates should be stored and managed. An employee training record should be maintained for each employee. This may include the following: • Training completed before joining the airport organization • Training completed during the employment phase • Further training programmed or considered desirable Documentary evidence such as copies of training certificates, college certificates, and the like may be attached or referred to in the training record or maintained in a personnel file. SMS Operation 141 At small airports, a formal systemic approach to training is not feasible and the process should be simplified. For such cases, it is likely that only one or two air- port employees will have a more comprehensive SMS training. Other employees will require only SMS indoctrination training that may be provided on the job by the SMS Manager. changes to procedures are made. Refresher training should be programmed and recorded when completed.

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Safety Management Systems for Airports, Volume 2: Guidebook Get This Book
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TRB's Airport Cooperative Research Program (ACRP) Report 1: Safety Management Systems for Airports, Volume 2: Guidebook explores what constitutes an airport safety management system (SMS). The report examines SMS components and their interactions, and offers guidance in the planning, implementation, and operation of an airport SMS. It also provides detailed information on how to carry out each of the necessary SMS processes.

This guidebook supplements ACRP Report 1: Volume 1, which provides an overview of SMS and explains how a systems approach to safety management can benefit both the safety and business aspects of airports.

http://onlinepubs.trb.org/onlinepubs/acrp/acrp_rpt_001a.pdf

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