# Safety Management System Program Manual

Austin-Bergstrom International Airport Austin, Texas

Prepared by: Jacobs Carter Burgess Safety Management System Team Fort Worth, Texas

October 28, 2008

### TABLE OF CONTENTS

1.0 INTRODUCTION TO SAFETY MANAGEMENT SYSTEMS (SMS) ... 1

2.0 GAP ANALYSIS .................................................................................. 4

3.0 HUMAN FACTORS (HF) .................................................................... 5

4. 0 SAFETY POLICY & OBJECTIVES ..................................................... 6

5.0 SAFETY RISK MANAGEMENT ........................................................ 13

7.0 NON-PUNITIVE REPORTING SYSTEM .......................................... 35

8.0 SAFETY PROMOTION ..................................................................... 37

9.0 SMS PROGRAM IMPLEMENTATION .............................................. 44

11.0 APPENDICES ................................................................................... 49

Appendix 1 - Definitions .............................................................................. 50 Appendix 2 – Human Factors ..................................................................... 55 Appendix 3 – Performance Indicators ........................................................ 59 Appendix 4 - The Twenty-One Elements of SMS ....................................... 62 Appendix 5 – Safety Risk Manage ment Decision Report (SRMDR) .......... 64 Appendix 6 - SRMDR Su pplemental Hazard Analysis Worksheet ............. 66 Appendix 7 - Forms .................................................................................... 69

12.0 LIST OF FIGURES ........................................................................... 73

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### 1.0 INTRODUCTION TO SAFETY MANAGEMENT SYSTEMS (SMS)

1.1 Introduction

This Program Manual describes the application of Safety Management Systems (SMS) at the Austin Bergstrom International Airport (ABIA). It is a resource intended for the City of Austin D epartment of Aviation (DoA) executives, managers, safety officials, and all employees

. This manual further establishes a systems approach to safety management which ben efits both the safety and business aspects of the Airport. It describes the essential compon ents of SMS and also incorporates the International Civil Aviation Organization (ICAO) and anticipated Federal Aviation Administration (FAA) policy for airport SM S programs. Furthermore, it includes

valuable lessons learned from a June 20 08 Gap Analysis in SMS implementation

efforts at ABIA.

1.2 Background and Guidance on SMS

1.2.1 ICAO Requirement for SM S at Member Airports

In November 2005, the International Ci vil Aviation Organization (ICAO) amended Annex 14, Volume I (Airport De sign and Operations) to require member States to have certificated international airports, est ablish an SMS Program. The FAA supports harmonization of international standards, and is working to make U.S. aviation safety regulations consistent with ICAO st andards and recommended practices.

1.2.2 Current Initiatives Within FAA Regarding SMS

The FAA is beginning to implement SMS withi n its own organizatio nal groups. Current initiatives include the following:

• Flight Standards: Flight Standards is assisting ai rlines and operators in developing SMS programs. They have de veloped an Advisory Circular (AC)
120-92, Introduction to Safety Management Systems for Air Operators

.

• Air Traffic: Air Traffic has est ablished Safety Risk Management (SRM) processes in their organization, with the publication of FAA Order 1100.161, Air Traffic Oversight . Air Traffic has begun nationally training their employees on Safety Risk Assessments, Analysis and Mitigation.

• Airport Operators: In 2007, the FAA Airports published AC 150/5200-37, Introduction to Safety Management Syst ems (SMS) for Airport Operators. This introduction provided the basic overview of SMS SRM principles. No formal implementation guidance wa s provided. The FAA la ter initiated grants to several certificated airports to dev elop SMS programs under an Airports Improvement Program Grant.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 2 1.2.3. FAA Pilot Program fo r SMS at Airports

In 2007, the FAA established a pilot program for developing SMS at airports in the U.S. A total of 21 air carrier airports were selected by FAA for inclusion in the pilot program and each airport was provided with a $250,000 feder al grant to fund their SMS program. ABIA was one of the airports selected by FAA to participate in this important pilot program that will help FAA develop a nati onwide standard for SMS at airports with commercial air service. After receiving technical proposals and statements of qualifications, t he Jacobs Carter Burgess Team was selected by ABIA to conduct a SMS study of the airport and prepare this program manual.

1.2.4. Potential Inclusion of SMS Into Part 139 Certification of Airports

The FAA is strongly consider ing the inclusion of Safety Management Systems into the Part 139. This process will require a No tice of Proposed Rule Making (NPRM) to incorporate it into federal law. This proc ess may take as long as 2 to 3 years to become law and implemented by the FAA. In the inte rim, airports are being encouraged by the FAA, to l ook at their safety program s and consider implementing an SMS program that is tailored to thei r airport before the FAA adopts regulations mandating the implementat ion of SMS programs.

1.3 Purpose of SMS

Historically, aviation safety has been built upon the reactive analysis of past accidents

and the introduction of corrective actions to prevent the recurrence of those events. With today’s extremely low accident rate, it is increasingly difficult to make further improvements to the level of safety by us ing this approach. Th erefore, a proactive approach to managing safety has been develope d that concentrates on the control of processes rather than solely relying on inspection and remedial actions on end products. This innovation in aviation system safety is called a Safety Management System, an expression indicati ng that safety efforts are most effective when made a fully integrated part of the business operation.

It is now generally accepted that most avia tion accidents result from human error. It would be easy to conclude that these errors indicate carelessness or incompetence on the job, but that would not be accurate. Investigations ar e finding that the human is only the last link in a chain that leads to an accident. These accidents will not be prevented by merely changing people; increased safety can only occur when the underlying causal factors are add ressed. Enhancing overall safety in the most efficient manner requires the adoption of a syste ms approach to safety management. Therefore, every segment and level of an organization must become part of a safety culture that promotes and practices risk reduction.

Safety management is based on the premise t hat there will always be safety hazards and human errors. SMS establishes processes to improve communication about these

risks and take action to mini mize them. This approach w ill subsequently improve an

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 3 organization’s overall level of safety. The application of a systemat ic, proactive, and well-defined safety program (as is inherent in a SMS) allows an organization producing a product or service to strike a realistic and efficient balance between safety and production. The forecasted growth in air transportation over the next 20 years, will require new measures and a gr eater effort from all av iation producers - including airport operators - in order to achieve a cont inuing improvement in the level of aviation safety. The use of SMS at ABIA can contribut e to this effort by increasing the likelihood that airport employees will det ect and correct safety problems before those problems result in an accident or incident.

1.4 ABIA SMS Program Manual

This ABIA SMS Program Manual provides the framework fr om which ABIA will begin to build their program. The program may re quire some additional outside resources to assist ABIA in maturing the pr ogram over the next several years. This SMS Program Manual describes a Safety Management S ystem (SMS) and explains how a systems approach to safety management will benefit bot h the safety and business aspects of the Department of Aviation.

The SMS Program Manual for ABIA includes the following:

• A summary of the Gap Analysis that was conducted by the Jacobs Carter Burgess Team in June 2008 is provided in Section 2;

• A discussion on the import ance of human factors in the development of an SMS for any organization is provided in Section 3;

• The four key components of SMS, Safety Policy & Objectives, Safety Risk Management, Safety Assurance, and Sa fety Promotion are presented in Sections 4, 5, 6, and 7, respectively;

• A discussion on the import ance and usefulness of Non-Punitive Reporting is provided in Section 8; and

• A Program for SMS Implementation at ABIA is presented in Section 9.

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### 2.0 GAP ANALYSIS

2.1 Overview

The purpose of the Gap Analysis was to document existing gaps or deficiencies in the airport’s current procedures, policies, documentation, ac tions and operations, as outlined in the Airport Certif ication Manual (ACM). The 21 basic safety elements of SMS, were utilized in the evaluation, development and management of the SMS Manual and Program. Appendix 2 provides additional in formation regarding the 21 SMS safety elements.

2.2 Airport Certification Manual (ACM)

Airports with certificated air carrier servic e must be certified under the Federal Aviation Administration (FAA) guidance under the Code of Federal Regulations, Title 14, Part
139, Certification of Airports . Under the approval of the FAA, Airports establish an airport certification that is tailored for their airport, which is in compliance with Part 139.

This manual establishes the standards a nd documented processes by which airport operators manage and monitor the sa fety of their airport.

While the ACM address critical safety elem ents of an airport, they typically do not address the means, processes and analysis for optimal system safety, as an SMS program does.

2.3 SMS GAP Analysis at ABIA

The Gap Analysis performed at ABIA compared current stat us relative to the 21

elements of the SMS Manual and Program in the FAA SMS Pilot Study Participants Guide. The Gap Analysis was conducted fr om April through May 2008 by the Jacobs Carter Burgess Team. The Gap A nalysis was accomplished through:

• various interviews with airport staff;

• review of current documentation;

• published guidance & best practices;

• observation of operations at ABIA;

• surveys; and

• comparison of the data collected to the ACM, 14 CFR Part 139, and the 21 safety elements of SMS.

The GAP Analysis Report ident ified which of the 21 elements matched the FAA’s SMS guidance materials and which of those did not. The report then recommended changes that would create continui ty with the elements of SMS.

The GAP Analysis Report was provided to ABIA management, in a separate document, for their review and reference, as they begin to implement their SMS

program.

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### 3.0 HUMAN FA CTORS (HF)

Human Factors is the area of study that seeks to maximize the relationship between people and systems in order to improve performance, safety, and reliability. Human Factor systems involve the interaction between people, equipment, and organizations

. Systems include equipment, proc edures, or organizations or t eams. The integration of Human Factor awareness into the SMS proc esses will create a solid foundation for successful and continuous safety improvement.

People : The quality of airport operati ons is dependent upon the numbers of personnel available for operations (manpowe r), the aptitude, skill, experience, and training of those employees (per sonnel quality), and a keen awareness of human information processing issues that have significant affects on safety (attention, memory, fatigue, visual and audio perception, team communication, etc).

Equipment : The design of equipment, and/ or procedures on how to use equipment, may also have significant impact on system safety. Awareness of Human Factors involved in the equipment used by an organization, especially new equipment, is critical in identifying issu es might result in a safety incident.

Organizations : Organizations are also systems. ABIA is composed of different departments, divisions , offices, crews, and tena nt organizations that all work and interact together. Each develops and operates under many policies and procedures, some shared, and some i ndividual for each particular group. Human Factors plays a role when procedu res from one group are unknown or unclear to the others, in teract unexpectedly with other procedures, and can have detrimental affects on overall safe operations.

SMS and Human Factors ar e inextricably linked. All em ployees should be vigilant in the detection of system “desi gn vulnerabilities”, (people, equipment, or organizational). Department of Aviation personnel must cont inuously monitor for system parameters at “critical mass”, i.e. fatigue, physical requ irements, stressors, num bers and quality of personnel or equipment, and organizational iss ues (values, norms, climate, etc.). Each of these factors can degrade safety clim ates slowly, but surely, if they are not identified and action taken in a timely manner.

Employees will be responsible to monitor and communicate safety issues and concerns. This SMS Manual provides t he guidance to establish those methods, processes, principles and practices to achieve an improved recognition of human

factors.

Additional information on Human Fact ors is available in Appendix 2, Human Factors

.

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### 4. 0 SAFETY POLICY & OBJECTIVES

4.1 System Safety and SMS

System safety is the application of engi neering and management principles, criteria, and techniques to achieve an acceptable leve l of safety throughout all phases of a
system.

Achieving this definit ion of system safety is the primary objective of SMS. A wellstructured SMS provides a systematic, explicit, and comprehensive process for managing risks. This process includes goal setting, planning, documentation, and regular evaluation of performance to ensure that goals are being met.

4.2 Safety Policy

The Aviation Department Safety Policy def ines the fundamental approach to managing safety that is to be adopted within the or ganization. The Safety Policy further defines the organization’s commitment to safety and overall safety vision, and empowers the organization to fulfill the values and commitments of top management. The Department’s new safety policy is:

“The City of Austin Aviation Depart ment is committed to implementing a Safety Management System and maintaining a safe, healthy and sustainable working environment fo r our people, our customers, our partners and contractors, and t hose we are employed to serve. Employees of the City of Austin De partment of Aviation are responsible for promoting a safe environment at Austin-Bergstrom International Airport.”

This safety policy is the cornerstone for sa fety within the Department of Aviation and operation of the airport. It pr ovides the framework for management to put in place the organization and arrangements for carrying it out. The Department of Aviation will actively encourage employee adherence to th is policy and the adopt ion of a similar policies by all companies and State and Federal agencies operating on airport property.

4.3 Safety Goals & Objectives

4.3.1 Safety Goals

The City of Austin Department of Aviation is committed to achieving the following safety goals :

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 7 1. Implement and maintain an appropriate Safety Management System with a structure to manage, supervi se and safely accomplish all aspects of aviation activities which fall within the Departm ent of Aviation’s ar ea of responsibility;

2. Achieve the highest levels of avia tion safety performance by meeting or exceeding local, state and federal legislative and regulatory requirements regarding airport operations;

3. Seek to achieve no harm to peopl e and minimal impact on the environment through our business operations;

4. Systematically manage aviation safe ty matters through periodic and rigorous audits and reviews of the safety implications of all our aviation activities;

5. Consult with staff and encourage active participation at all levels within our businesses;

6. Learn and benefit from our experiences and the ex periences of others;

7. Promote a culture in wh ich all Department of Aviati on employees share these commitments; and

8. Increase safety awareness among our business partners and encourage their participation in the program.

4.3.2 Safety Objectives

To achieve these goals, the City of Austin Department of Aviation will establish, develop, implement and maintain effective av iation safety objectives, that should incorporate the following:

• Identify, access, and manage hazards, impacts, and risks from aviation activities;

• Train and deploy competent people and allocate responsibilities and tasks commensurate with individual skills;

• Set, achieve and report against objecti ves and measurable safety performance indicator targets to demonstrate continual performance improvement;

• Identify areas for improvement thr ough comprehensive incident reporting and investigation; and

• Maintain a culture that encourages t he free and honest reporting of safety

issues.

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 8 4.3.3 Safety Accountability

The long term success of SM S is based on the assignment of responsibilities by Department of Aviation top executives. Department of Aviation supervisors must understand when safety risk management pr ocesses are necessary, and when to elevate decisions and the supporting info rmation to a higher management level.

Key elements of SMS accountabi lity within an organization are;

• The SMS Program Manual ch apter on safety policy addresses the responsibility and accountability, including written guidan ce regarding the safety authorities and responsibilities of all key per sonnel assigned to the airport.

• Identification of staff that is responsible for administr ation of the overall SMS. Responsible staff report to the highes t level of Department of Aviation management to assure appropriate consideration of all reports, recommendations, and issues.

• Personnel who are responsible for SMS are employed by the Department of Aviation and are provided with the necessa ry resources to fulfill their duties.

• The responsibilities associated wit h SMS are clearly defined within job descriptions of Department of Aviation staff along with identified lines of communication within the organization.

• The Department of Aviation has est ablished a safety council. The safety council acts as a source of expertise to the Department of Aviation and is cochaired by the organizations top m anagement and the predominant airline.

4.3.3 Safety Responsibilities

Safety management responsibility and a ccountability are intertwined. Each Department of Aviation employee acknowle dges the importance of safety and takes a leadership role in the conti nual development of the princi ples of SMS in their duties and assignments. Although individuals must be accountable for their own actions, top management is accountable for the overall per formance of the Depar tment of Aviation employees that report to them.

Since accountability is a two-way street, Department of Aviation directors, managers and supervisors are also accountable for ens uring that their subordinates have the resources, training, experienc e, etc. which is needed for the safe completion of their assigned duties.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 9 The following describes key managem ent responsibilities for SMS:

Department of Aviation Executive Director:

Subject to the direction and control of the City Manager and Assistant City Manager, the Executive Director has overall responsibility for the safety of passengers and Department of Aviation employees. The Executive Director also has an overall safety consultation, facilitation and monitoring role for the airport’s tenants, concessionaires, airli nes, contractors, suppliers, and service providers.

The Executive Director’s areas of responsibility include the following:

• Ensure that the safety policy and management system is produced, kept up to date and meets Depar tment of Aviation policies and procedures.

• Take a leadership role in the air port’s safety program and ensuring that safety never becomes subordinate to financial matters.

• Develop an annual business plan (i.e. including the capital program) that is sufficiently resourced to achieve compliance with the airport safety policy and management system.

• Appoint safety conscious managers, monitor their performance and ensure that safety is given a high priority within their training and development plans.

• Consider safety issues when making changes in the airport’s organization structure and business processes.

• Clearly define accountabilities and re sponsibilities for all staff for the delivery of safety performance.

• Set and enforce policies, standards and procedures that contribute to the success of the airport’s safe ty policy and management systems.

Director, Airport Oper ations and Maintenance:

The Director is accountable for defin ing, deploying and monitoring SMS strategy and compliance processes to enable the Department of Aviation to have safety focused strategic plans and compliance management. The Director has prime responsibility for supporting t he Executive Director to comply with

their duties.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 10 The Director’s areas of respons ibility include the following:

• Provide a leadership role in Depa rtment of Aviation safety program.

• Ensure that safety does not bec ome subordinate to financial matters.

• Champion safety at the D epartment of Aviation meetings.

• Support all departments and functions to monitor safety performance across lines of responsibility.

• Ensure safety improvement obj ectives are set and implemented.

• Ensure the Operations and Maintenance division policies, standards, procedures and practices contribute to the success of Department of Aviation Safety Policy and Safety Management System.

• Appoint safety conscious direct reports, monitor their performance and ensure safety is given the highest priority within their training and development plans.

• Ensure Planning and Engineering coordinate with Operational divisions to incorporate safety during main tenance and construction projects.

• Consider safety when making or recommending changes in the airport organizational structure and business process.

• Ensure proper liaison takes place between the activities of Airport police

officers and TSA in so far as their shared risk activities fall under the jurisdiction of the Executive Director.

• Ensure there is coordination with those who have operational functional responsibilities which might affect safety.

• Enforce compliance with all safety re lated legislation applicable to the management of the air port and facilities.

SMS Coordinator

The SMS Coordinator is accountable to the Director - Airport Operations and Maintenance for defining, deploy ing and monitoring the Operations department’s strategy and compliance pr ocess to enable the department to have safety focused plans and compli ance management. The SMS Coordinator is also responsible for maintaining a safe operating environment at the Airport.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 11 The SMS Coordinator’s areas of responsibility include the following:

• Manage staff and resources to ensure compliance with and maintenance of airside safety standards and recommended practices in accordance with the requirements of the Feder al Aviation Administration, International Civil Aviation Organization, Title 14 CFR Part 139, the ABIA Airport Certification Manual and Airside Directives.

• Set a compelling purpose and visi on for the Operations Division.

• Lead the Airport’s Safety Managem ent System, including emergency planning, and co-ordinate, supervi se and control resources during emergency incidents, aircraft recove ry operations, adverse weather conditions, equipment service iss ues and unscheduled movements.

• Use best efforts to ensure safety does not become subordinate to

financial matters.

• Set objectives for safety improvement and provide support to achieve

them.

• Use best efforts to ensure policie s, standards, procedures and practices are aligned at all times.

• Recruit, motivate and monitor safety conscious direct reports, identifying suitable development plans.

• Notify management of all operational matters that may influence or impact their areas of control.

• Maintain and develop constructive re lationships with all stakeholders in the safe and efficient operation of the airfield.

• Use best efforts to ensure Operati ons business plans are sufficiently resourced to achieve compliance with the safety management system.

• Use best efforts to ensure “best practice” operational standards and procedures are identified, documented and implemented.

• Use best efforts to ensure the safe movement of aircra ft by coordinating with the Airport Traffic Control Tower, meteorol ogical office, airlines, airport fire/rescue and police, especially when affected by adverse weather conditions, equipment, in cidents, emergencies or other disruptions.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 12 • Regulate aircraft ground engine runni ng, night movement, airfield/ramp construction, airfield obstruction sa feguarding and airfie ld congestion in accordance with statutory regulations and Department of Aviation policy.

4.3.4 Department of Aviation SMS Organi zational Line of Communications

The fundamental success of SMS relies upon unobstructed lines of communications throughout the organization. This communicati on, whether it be horiz ontal or vertical, reflects the desire of top management to support safety at every level.

The Department of Aviation is organized in a manner in tended to be resilient to

hazardous situations and its ab ility to reduce risks. Li nes of succession have been established across the organization to ensure responsible safety management. The organizational flow chart, shown in Figure 3.1 below, is intended to provide for the orderly approach to documentat ion and information management.



### Figure 4.1 - Lines of Succession for Safety Management Systems (SMS)

Austin Bergstrom International Airport – Aviation Department

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 13 

### 5.0 SAFETY RISK MANAGEMENT

5.1 Overview

Risk is defined as the possibility of loss or injury. Safety Risk Management (SRM) is the proactive process that can be used to identify, assess, and mitigate risks or potential hazards that may lead to loss or injury.

SRM is both reactive from a historical persp ective and proactive from a speculative or anticipatory analysis. By reviewing past occurrences and considering changes in progress, a probability and severity assessm ent can be reached utilizing the risk matrix process and charts.

SRM is utilized as an immediate resoluti on to a dangerous hazard or in planning during procedural changes, implementati on of new equipment, expanded or new personnel responsibilities and ph ysical changes at the airpor t, etc. When changes are proposed or occur within an organization, managers must decide to what extent the SRM process will be initiated. The mitigation of the risks, revisions, modifications, and contingency arrangements requires consci ous management decisions to approve, fund, schedule, and implement one or more risk strategies. Any changes to existing procedures or systems can introduce added haz ards which may result in increase

risks.

SRM provides the process for evaluation of the various risks and the systematic analysis, mitigation and corrective course of action to eliminate the risk or reduce the probability and severity of the risk to an acceptable level. The process can be implemented in:

• The design of systems, pr ocedures, and/or organizations;

• Any proposed changes to existing syst ems, procedures, equipment, personnel and/or environment; or

• Hazards identified during operations or safety assurance functions.

5.2 Safety Risk Management Process

A project, regardless of size, may have hazards inherent to the planning and developing stages before implementation ever begins. The system may involve analysis and understanding of hardware considerations such as, equipment, machinery, electronic equipment, furnishings or physical areas such as locations, both inside and outside, terminal or AOA spaces as well and human factors involvement.

An organization, whether a small shop or the entire airport may be susceptible to hazards due to incomplete understanding and/or personnel tr aining, improper planning, inattention to rules and r egulations, and ineffective management.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 14 Furthermore, the description and definition of the operational context of a hazard under consideration must be as accurate as possible

, as the identification phase of the process begins. A full description of the physi cal area and/or activity area is of utmost importance to understanding how procedures and processe s function within the physical environment.

The Safety Risk Management process consists of five functional phases:

Phase 1: Describe the procedure, pr oject, system, and/ or organization;

Phase 2: Identify the hazard;

Phase 3: Analyze the risk;

Phase 4: Assessing the risk; and

Phase 5: Mitigation/treat ment of the risk.

These five phases are the heart of the SRM process and define the methodologies and strategies to successfully prepare for a historical eventuality or the unseen realities of new events. A comprehensive breakdown of each of the five phases of SRM are listed below, showing the systematic process, in cluding the intent, scope, identification, evaluation levels , mitigation strategies, and the final treatment of the risk and process itself.

5.2.1. SRM Phase 1: Describe the Procedure, Projec t, System, and/or Organization.

• Define the use, intended functi on, configuration and/or task;

• Define the scope, objectives, and utilization interactions;

• Examine Human Factors considerations; and

• Examine information technology (hardware/software) components.

The first phase of SRM is a descriptive and thorough explanat ion of procedures, projects, systems and organizations can assist all personnel in procedural understanding. This l eads to proper training

, eliminating predet ermined incorrect assumptions, procedures or actions. A hazar d may exist within a procedure, or set of procedures, that can be mitigated by a simp le one or two word change to that procedure.

5.2.2. SRM Phase 2: Hazard Identification

• From reports of hazards, safety conc erns, evaluations of system procedures;

• Data collection – paper/el ectronic documentation;

• Analysis and assessment of tracked and historical data;

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 15 • Considerations of lessons l earned and previous experiences; and

• Communication of collected data throughout the process.

The second phase of SRM is the identificati on of hazards. Of pr imary importance to

the identification of the hazar d is the accuracy of percepti ons derived in the planning discussions of new systems, pr ocedures, projects, organization s and/or safety reports. Hazards may be as obvious as the “smoking gun” or buried in a maze of statistical history. Frequent review of historical dat abase information reinforces the importance of accurately and consistently adding info rmation to established database programs.

5.2.3. SRM Phase 3: Analyze the Risk for each Hazard

• Identify existing controls;

• Determine severity and likelihood of risk;

• Ask the open-ended questions – What if...?, Why did...?; and

• Determine trigger mechanisms and various outcomes.

The third phase of SRM is the analysis of risk. Once the confines of the hazard area

have been defined and the hazar d has been identified, analysis of the hazard can begin. Depending on the area and identification, existi ng controls for the procedure, project, system /or organiza tion must be identified and reviewed. Asking the open ended questions like “Why did...?” and “What if ...?”, will assist in finding the cause for an event occurring and/or preparing for t he crucial decision-making process or operational changes. Embedded within are various “trigger mechanisms”, precipitating events, or certainties of various outcome s. Through the analysis of each risk, the severity and likelihood of the risk can be determined.

5.2.4 SRM Phase 4: Assess the Hazard

• Assess the severity and likelihood of occurrence;

• Prioritize the risk and results;

• Select hazards requiring detailed risk mitigation;

• Ascertain the management level for decision-making authority; and

• Identify the party responsib le for the risk acceptances.

The fourth phase of SRM is assessi ng the hazard or degree of risk. With the determination of the severity and likelihood of the hazard, assessment using the Risk Matrix table can define the risk and assist in assign ing a priority to the risks or to each

individual risk involved. Some risks will r equire detailed risk mitigation and other may have a more simplistic solution. Management levels of decision-making authority should be set forth and recognized within the SRM process. Management will also be

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 16 responsible for identifying and assigni ng managers responsible for the risk
acceptances.

5.2.4. SRM Phase 5: Mitigate and Treat the Risk

• Identify mitigation options – Select best response and risk treatment plans;

• Define management levels required to ascertain risk decisions;

• Document risk options and treatment;

• Hazard reduction or elimination;

• Reapply SRM process on substituted or eliminated risks

• Track changes and monitor for effectiveness;

The fifth phase of SRM is mitigating and treati ng the risk. Regardless of the method of notification of a hazard or the upcoming risk associated with proposed changes, the SMS Coordinator will consider best response options. Depending on the severity of the hazard or the complexity of an upc oming project, the SMS Coordinator will respond to the appropriate level of management required and implement the notification process. Each step of the process, regardl ess of the complexity, will be documented on the Safety Risk Management Document Report (SRMDR), which will certify that the hazards we re properly identified, analyz ed, assessed and mitigated. If the SRMDR results in a judgment of no risk or is of such severity as to cause a Safety Risk Management Panel (SRMP) to be conv ened, the process will acceptably reduce or eliminate the hazard. Upon completion, the SRM process will be reapplied on the

substituted or eliminated risks to validate the thoroughness of the process. The mitigation changes will be continually

tracked for their effectiveness and, if required, training and retraining shall be implemented.

5.2.5 Safety Risk Management Life Cycle

Safety Risk Management is a continuous cycle that must be repeated to ensure the systems integrity. The five phases of SRM provided guidance from the beginning of hazard identification through the mitigation of those hazards. An effective SRM program is further

enhanced with the continuous a ssessment of the system to ensure that mitigation Figure 5.2 - The SRM Life Cycle

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 17 implemented is effective and that no new hazards are being introduced as a result of that mitigation implementation.

Figure 5.2, The SRM Life Cycle , illustrates the continuous SRM Life Cycle process that must be implemented to comp lete the system safety process.

5.3 Risk Assessment

Each hazard identified for assessment shall be evaluated from the standpoint of both severity and likelihood of occurrence. Each hazard will be plotted on the Risk matrix to

determine their initial Risk and then their resu lting Mitigated Risk. Mitigated Risks with a remaining HIGH rating is unacceptable.

Using the Predictive Risk Matrix shown in Figure 5.1, the se verity and likelihood values will identify a chart position to determine the level of risk a ssociated with the hazard.

The definitions of Likelihood and Severity are provided in Figures 5.2 and 5.3, respectively. This simple to use four by four Predictive Risk Matrix block chart has been developed for ABIA to facilitate the assessment of the level of risk.

. High Risk level occurrences are unacceptable and should be promptly mitigated to an acceptable level of safety.

Moderate-High level of occurrences, are gener ally unacceptable, but with the implementation of appropriate contro ls, the occurrence could become an acceptable risk.

Medium level of occurrences, are generally acceptable, providing the appropriate safety controls have been established.

Low level occurrences, pose little or no risk and have adequate levels of control

established. 

### Figure 5.1 - Predictive Risk Matrix

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 18 Figure 5.2, Likelihood Levels , provides definitions for diffe rent levels of likelihood: Improbable, Remote, Probable, and Frequent. When assessing the Likelihood of each hazard, the use of these definit ions will provide the most consistent results for multiple

hazard assessment.

Figure 5.3, Severity Levels , provides definitions for different levels of severity: Catastrophic, Major, Minor, and Minimal. When assessing the Severity of each hazard, the use of these definit ions will provide the most consistent results for multiple

hazard assessment.

5.4 Safety Risk Reporting

Safety reporting methods are an essential tool for tracking and collecting critical information for analysis and mitigation of hazards . Consistency in collecting critical data is best performed through the use of well designed reporting forms, which details the specific information essential for fu rther analysis. Collected data can then be integrated into airport electronic re cords for long term trend analysis. 

### Figure 5.2 – Likelihood Levels

Figure 5.3 – Severity Levels

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 19 Effective safety risk reporting methods include:

• Safety reporting forms with associat ed policies defined and printed on the safety reporting forms and disp layed at distribution points;

• Safety reports containing Date, Ti me, Description, and any extenuating conditions, such as weather. Reports will contain Name, Department, phone

and e-mail contacts which will be det ached from the report by the SMS Coordinator. Anonymous reports will be accepted, but discouraged;

• Computer safety reporting programs t hat are separate from log-in, access and personal computer modes ;

• Safety Reporting forms distributed to all departments and openly displayed;

• Collection boxes available at numerous locations for ease in collection;

• A published telephone HOT Line fo r reporting safety concerns; or

• In person

5.5 Communications

The SRM lifecycle is shown in Figure 5.2. The communicati on of safety issues and

risk resolutions are critical elements of SR M program. Information sh aring of what risk existed, how it was identif ied, why it occurred, and ho w the risk was mitigated better educates all personnel to develop a keen awar eness of safety hazards. This in turn develops a strong safety culture throughout the organization and develops trust and appreciation for making a safer working environment for all.

Communicating feedback can be accomplished through:

• Safety recognition and/or awards programs;

• Stakeholder meetings, such as Safety Council, SMGCS Working Group, Wildlife & BASH, Emergen cy Plan, Snow & Ice and Project Coordination or Construction meetings;

• Bulletin boards;

• Newsletters;

• Computer briefings at sign-in; and

• E-mails to personnel.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 20 • NOTAMS

5.6 Benefits of SRM

The proactive management of risks and continuous safety monitoring through the SRM Life Cycle process will provide a fo rmalized and proactive approach to systems safety at ABIA. Incident reporting progr ams, including self-inspections, are necessary to identify immediate hazard concerns and latent human, equipment, and procedural deficiencies existing before accidents occur. Information gathered from SRM reporting systems leads to internal feed back and trend monitoring programs

, allowing the

measurement and assessment of hazards and the methods to proactively counteract

the risk before accidents/incidents occur.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 21 6.0 SAFETY ASSURANCE

There are several different methods to assu re that safety goals and objectives are being met. These methods include:

• Performance Indicators

• Trend Analysis

• Safety Data

• System Safety Audits

• Corrective Action

Each of these methods elaborated in more detail below.

6.1 Performance Indicators

Identification and tracking of pe rformance indicators is critical to any program or system, and even more so with a safety syst em such as SMS. With SMS however, the intent is to not be anchored in the past, but rather to look ahead and identify and resolve issues before they result in accidents/incidents.

In the initial stages of impl ementing SMS, the se lected performance indicators and the data to support them must be those that focus on the degree of compliance with regulatory requirements and t he successful implementation and existence of the new system. As the system matures, the per formance indicators and the data to support

them need to evolve into areas that more fully evaluate system effectiveness. Performance indicators should identify po tential areas of weakness so that SMS efforts can be properly focused.

Initially, as SMS is being im plemented, the performance indicators will be more global in nature. As the system becomes more ma ture, the performance indicators can be expanded based on workforce selected issues. In the most mature stage of implementation, performance indicators will be much more diverse with individual work centers developing their own set of perform ance indicators and identifying the data necessary to support them. At any stage in system development though, performance indicators and the data needed to support them can constitute a smattering of indicators across the entire development spectrum. Simply put, SMS data requirements must be established in suppo rt of selected performance indicators and revised as the indicators change with system development.

In the area of regulatory compliance, the Airport current ly collects an abundance of data concerning the airfield through the Ai rport Security and Operations Compliance System (ASOCS) and the Computerized Maintenance Management System (CMMS) databases. That data can adequately suppor t performance indicators centered on regulatory compliance. Data to support performance indicators that concern SMS implementation are less readily available and in most cases will have to be developed.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 22 The following performance indicators will be used initially as a minimum to measure implementation of the ABIA SMS:

• Management's visible parti cipation in safety;

• Employees’ understandi ng of the SMS;

• Employees’ evaluation of managem ent’s commitment to SMS;

• Voluntary Safety/Le ssons Learned Reporting;

• Employee Safety Surveys;

• Audit Findings; and

• SMS Training

The data to support the first three will come primarily from empl oyee surveys, and data for SMS training will be available in the Tr aining Registration and Administration IntraNet (TRAIN) database. New record k eeping or analysis syst ems will have to be developed and implemented fo r the others.

Table 6.1, Examples of Performance Indicators , presents 14 examples of potential performance indicators for ABIA. Also shown in Table 6.1 are the specific

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 23 performance measures, how they shoul d be accomplished, and who has the responsibility for collecting and reviewing the performance indicator information. As shown, the SMS Coordinator has the res ponsibility for gathering, compiling, and analyzing the performance indicator data.

Table 6.1 is additionally provided in full size in Appendix 3, Performance Indicators.

6.2 Trend Analysis

Trend Analysis is an integral part of any SMS performance indicator program and an extremely valuable tool for the timely identification of embryonic hazards allowing timely analysis and mitigation before these hazards result in accidents/incidents. It is, however, essential that trend analyses be based on properly identified and tracked performance indicators both “lagging or trailing” and “leading,” and it must be

understood that these indicato rs will have to be modified or changed over time to

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 24 continue to produce realistic snapshots of an organization’s safety program

effectiveness.

Trailing or lagging indicators recount hist ory – past events. They can include such things as accident/incident numbers, runway incursions, bird strikes, etc. Trailing

indicators are the most common indicators used by airports in tracking the success or failure of their safety programs, but they do so in hindsight. They do little in the way of providing proactive, look ahead forecasting of potential safety pr oblems and program performance. That is not to say that they cannot be of so me assistance in identifying

trends.

Future trends can sometimes be identified by using the performance of trailing indicators if done so over longer periods of time and projecting that trend forward. For instance, a trailing indicator could numeri cally remain well within the acceptable guideline or performance standard for each month over a perio d of a couple of years giving a sense that the system is in good shape and nothing needs to be done. But showing that same data in a two-year trend analysis could indicate a trend that shows performance, though still accept able, has actually been trending downward with the ever increasing potential of an unacceptable accident/inciden t occurring in the not too

distant future if that trend is not reversed. In this way lagging indicators can be used as a forecasting tool, but they are not as effective as a good set of leading indicators especially when evaluating overall safety program performance.

Leading indicators look at thi ngs that do not necessarily affect system performance as it presently exists. Instead, they provide an evaluation of condition s and activities that precede and affect the occurrenc e of accidents or incidents in the months or years to come. Such things include changes in the operational and sa fety environments, training and management involv ement in safety. The follo wing are good examples of leading indicators for analyzing an organization’s safety program:

• The degree of commitment to safety and health;

• How highly both management and work ers value a safe workplace;

• The level of awareness that workers and management have of job related risks;

• Whether inspection and preventative maintenance programs are followed;

• The level or quantity of training provided;

• Total hours of trai ning provided; and

• The degree of activity of the Sa fety Council, Committees and Panels.

All of these can be leading indicators t hat show trends toward a continuation of acceptable or improving safety levels or issues that need to be evaluated and potentially mitigated. For instance, ther e may be a situation where all mandatory

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 25 training is being accomplished satisfying one of the trailing indicator performance standards or benchmarks, but t he number of hours of additional safety training has been declining over the last couple of years. This may portend a lessening of safety and an increased potential for accidents or incidents that will not s how up by solely analyzing trailing indicators until actual accidents/incidents occur. However by identifying this adverse trend through the tracki ng of a leading indicator such as “Total Training Hours,” a thorough evaluation can be conduct ed thorough the Safety Risk Management (SRM) review process and appropria te mitigation or changes to previous mitigation implemented.

Trend analyses should normally be performed with "Quantitative" data. This means survey questions should be multiple choice, true or false, rank order or constant sum. Survey questions that have te xtual input (Q ualitative) should normally

be avoided when the data is in tended for use in a trend analy sis since that introduces subjectivity into the process. However, sometimes textual input can point to an area(s) that would benefit from further, in-depth investigation.

The key in any trend analysis is the selection of the most appropriate indicators, both trailing and leading, with which to evaluate a system and have enough data to produce valid analyses.

6.3 Safety Data Development & Management

6.3.1 Existing Databases The Aviation Department utilizes seve ral non-integrated database programs and database tools, as shown in Figure 7.1, ABIA Data management Systems . Those affecting operations on the airfield are:

• TRAIN (Training, Registration
and Administration Intra Net);

• TMA CMMS (TMA
Computerized Maintenance
Management System);

• ASOCS (Airport Security and
Operations Compliance
System);

• RMS (Records Management
System);

• VERSADEX Computer Aided
Dispatch (CAD);

• Microsoft Excel;

• SQL (Structured Query
Language).

Figure 7.1, ABIA Data Management

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 26 In the cases of TRAIN and ASOCS, these programs have only limited statistical functions, but reports from these program s can be imported into Excel for further processing and SQL can be used for more complex processing if necessary. Microsoft Access is also available for use at the Airport.

TRAIN is a program that was developed within the City of Austin Information Technology Department about 12 years ago to fill a need the De partment had to track training of their personnel. Si nce that time, use of the pr ogram has expanded to every department in the City including the Departm ent of Aviation. There are abundant choices of reports availa ble within the program, a nd additional reports can be developed to meet specific needs as has been done for other city departments in the
past.

This program will continue to be used for scheduling and documenting training except

in those cases where other proprietary systems must be used such as for the NonMovement Area Training which is a proprietary system.

TMA CMMS is a computerized maintenance work order system that collects a vast

amount of data on maintenance activities th roughout the airport. An abundance of standard reports are available from this system and the system also has the capability to generate “third party” or ad hoc reports. This system can effectively provide needed data in support of nume rous potential SMS performance indicators.

ASOCS is used by Airfield Operations as the official record of 14 CFR Part 139 activities and also by Operations Securi ty personnel. The two users of this system

each have dedicated servers so there is no integration between them. This system has a good capability to generate user defined reports to satisfy a multitude of needs in support of SMS and to be an effective source of data to support numerous potential SMS performance indicators.

RMS is used by Fire and EMS for their official records. It contains a vast amount of

data on fire and EMS events that occur on t he Airport, but there is no segregation

between airside and landside events as ther e is only one “address” for the entire airport. Additionally, the Federal Health Insurance Portability and Accountability Act (HIPAA) rules limit availability of medi cal information for incident analysis beyond those investigations conducted by the Fi re Department and EMS themselves to whether an individual was “inj ured, treated and/or transport ed.” This provides only minimally useful information fo r any incident analysis or “lessons learned” program. The system is operated and controlled by the City of Austin Fire Department and any possibility of gaining approval for someone outside that Department to access the system directly is extremely doubtful. Howe ver, it may be possible that reports from

this database can be made availabl e to an SMS Coordinator.

VERSADEX is used for police functions. It cont ains a vast amount of data on police events that occur on the Airport, but like RM S, there is no segregation between airside

and landside events as there is only one address for the entir e airport. As with RMS, HIPAA rules severely limit medical information available for incident analysis outside of

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 27 a police investigation and use in any “lessons learned” progr am. When a review of the daily police “blotter” reveals an incident that may be of interest to an airport department, the basic information from that incident is shared with the appropriate airport department(s), but no monthly repo rts concerning incidents/accidents on the Airport are produced.

The system is operated and controlled by the City of Austin Police Department, and like the Fire Department’s RMS, it is ex tremely doubtful that approval could be gained for anyone outside the Department to have direct access.

A significant amount of data is warehou sed in several non-integrated database systems that have the potential to adequately support many of the data needs of SMS once the performance indicators and the data needed to support them are determined. Their full potential will be utilized before othe r systems are consider ed, especially in the initial stages of SMS Development.

6.3.2 Available Databases

There are several aviation specific statisti cal databases or busin ess intelligence tools on the market, but none have been identified as being used in any airport safety environment as yet. Rather, they are genera lly focused on airline and other aircraft operator applications. It is, however, antic ipated that the indus try will respond with a number of offerings specifically for airport use once the FAA establishes a requirement for Safety Management S ystems nationwide.

The programs currently available and which are envisioned to be the ones that would be modified to more fully satisfy the needs of airport operators are very capable programs that can access most major database resources. But, hist ory indicates that they require experienced personnel to properly and efficiently utilize them. They have

been shown to need considerable staff time to set up and run the analyses that may not be justified from a cost/benefit standpoint fo r individual airports especially at this early point in the FAA’s roadm ap to establishing airport SM S requirements. Therefore,

it is doubtful that ABIA would provide the level of demand to justify neither the direct

cost for such tools nor the cost to keep personnel adequately familiar with their operation for this embryonic progra m that is initially limited to the airfield portion of the airports.

On the positive side, there is one databas e program that was initially developed for airline use that appears very attr active if it could be revised to better serve the specific needs of airports. This program is the Av iation Safety Information System (AVSiS) that was originally dev eloped for use by airline safety managers in Great Britain to give them the “big picture” of safety within their organizations . It was purchased by the National Air Transport Associat ion (NATA) here in the Unit ed States for use by its member Part 135 carriers. This system is currently being investi gated by the Port of Seattle for its use in the airports applicati on, but even they acknowledge that it will require major modifications to effectivel y accommodate the needs of airports. To pursue this or at least determine if such changes can be made, t he Port of Seattle through its SMS Team conducts regular tele conferences with other interested parties

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 28 is forming an Airports Working Group to work with NATA who appears enthusiastic about the prospect of expanding its use to airports to line out the changes and enhancements needed to meet airport needs. If successful, this is a program that ABIA should consider as a safety enhancem ent measure if the data for all of the Airport’s safety programs c an be hosted on the system.

Hosting all of the Airport’s safety data on this system woul d not necessarily mean that there would be a single person overseeing sa fety programs throughout the Airport. Rather, it would mean is that there is a central electronic r epository for safety data that could be accessed by various approved m anagers for their use in monitoring and improving safety performance across the Airport.

An alternative and perhaps more cost-effe ctive approach would be for the FAA to sponsor the safety database system, with all airports providing data. Ideally, under this approach both airports and the FAA could run analyses. The FAA would have the ability to use data from individual air ports, to compile data on a regional and nationwide scale, with benchm arks and trend analysis standards established within the

program.

In summary, the programs currently availabl e and which are envisioned to be the ones that would be modified to more fully sati sfy the needs of airport operators require experienced personnel to properly and efficient ly utilize them. Cons iderable staff time is also required to set up and run the analys es. Therefore, the Department of Aviation cannot presently justify eit her the programs or the personnel to operate them.

6.3.3 Safety Data Development and Management Implementation

The various databases available in the Department of Aviation are adequate to support initial SMS requirements, and should be utilized to their full capabilities before new systems are considered. Slight changes in Performance Indicators themselves may allow existing databases to adequately support SMS as well when that would not otherwise be possible. To accomplish this, the SMS Coordinator as the individual responsible for safety data developm ent and management for SMS shall:

• Identify what data is needed to support individual performance and trend indicators,

• Determine which databases contain the needed data,

• Identify what existing repor ts can be used to extract the data or develop new reports that may be required,

• Adjust performance measures, if feasib le, to allow use of existing data and
reports,

• Develop new reporting requirements when needed data is not already available, identify the database to be used for war ehousing the data and develop reports

to extract the data.

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 29 6.4 System Safety Audits

The goal of the SMS audit program is not to focus on actual physical conditions.
Rather, it is to focus, at least initiall y, on evaluating the SM S management practices that are in place and determine if the system is being implem ented at a level consistent with industry best practices.

6.4.1 Audit Program

The Department of Aviation w ill develop an SMS Audit program that utilizes a checklist based on the Twenty-One elements of SMS contained in the Safety Management System Pilot study Participant’s guide th at was published by the FAA’s Office of Airport Safety and Standards (dated April 6, 2007). Thes e Twenty-One elements are listed in detail, in Appendix 5, The Twenty-One Elements of SMS . These audits will be performed no less frequently than annually with the first one occurring within twelve months following publication of the SMS Manual.

The majority of these audits will be conducted with internal resources, principally the SMS Safety Coordinator. In the event a more disinterested resource is desired, use of the Department of Aviation’s internal auditor or some ot her City resource will be

considered before utili zing an audit resource external to the Department and the City

of Austin.

6.4.2 Audit Program Implementation

To implement the SMS Audit Program that will ident ify deficiencies, identify corrective

actions and monitor those actions to co mpletion, the SMS Coordinator as the individual responsible for administration of the SMS Audit Progr am and evaluation of audit findings shall:

• Develop an Audit Checklist based on the Twenty-One Elements of SMS;

• Develop a tracking system to monitor correction of audit findings;

• Establish appropriate performance indi cators to gage the effectiveness of the audit program and identify data necessary to support them.

6.5 Corrective Action

A corrective action is a change implement ed to address a weakness identified in a system, normally a management system. Effe ctive management of corrective actions provides a vehicle for effective managemen t actions to improve safety and overall performance.

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 30 6.5.1 Corrective Action Program

Corrective actions can come from a multitud e of sources and can get quite numerous.

Those that come from sources such as a Safety Risk Management (SRM) Process, SMS audit or self-inspection, after action revi ews (incident, accident, project, etc.) will need to be monitored through utilization of a tracking system. Routine corrective actions such as those resulting from discr epancies identified during Part 139 Airfield Inspections will be specifically tracked by SM S if the item is open more than 30 days

The fundamental rules for any corrective action are:

• Clearly state the corrective action required

• Identify the responsible party or office

• Establish an aggressive but atta inable target date for completion

• Monitor progress toward meeting that date

A simple tracking system will be developed utilizing Micros oft Excel or a similar program to monitor progress toward closing corrective actions. Whatever the choice, the chosen system must allow for an adequate level of analysis and performance tracking.

The establishment and tracking of appropriate performance indicators to evaluate the Department of Aviation’s performance in meet ing target dates for Corrective Actions is essential to a successful program.

6.5.2 Corrective Action Program Implementation

To implement a SMS Corrective Action Program that will track corrective actions to completion, provide monthly progress r eports and measure performance, the SMS

Coordinator as the individ ual responsible for administr ation of the SMS Corrective Action Program shall:

• Develop a Corrective Actions tracking system;

• Establish appropriate performance indica tors to measure effectiveness of the Corrective Action Program;

• Include SMS Corrective Actions will be included as a standard agenda item for all meetings of safety committees involving airfield stakeholders.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 31 6.6 Lessons Learned

“Lessons Learned” is knowledge acquir ed from human error or an adverse experience. In some instances, lessons lear ned can also result from innovation. The knowledge derived from lessons learned provides the foundat ion for employees within an organization to improve a process or activi ty to work safer, more efficiently, and with a higher quality product.

6.6.1 Lessons Learned Program

A Lessons Learned Program is an impor tant component of ABIA’s Safety Management System (SMS). It allows for continuous system improvement and feedback, and like other aspects of SMS, there must be a m eans of measuring results. Lessons Learned do not come solely from such things as after accident/incident reviews, after project review s or some management related activity as is often the perception although they are prime sources. Instead, there are a multitude of sources both inside and outside an organization that can provide valuable knowledge to improve the safety environment.

Individuals within an organiza tion are good sources of le ssons learned, especially when it comes to offering inno vation or better ways to accomplish a task. Therefore, it is essential in any Lessons Learned Program to provide a means for individuals to make submissions in the same way as they are afforded the opportunity to report hazards or potential hazards they may observe or otherwise become aware of. No

matter what the source of the Lesson L earned, it must be significant, valid, and relevant to the organization. The Lesson Learned process itself is relatively simple. It calls for:

• Identifying Lesson Learned validity and applicability to the organization;

• Determining target gro up(s) for distribution;

• Determining appropriate distribution method(s);

• Making timely distribution;

• Accepting feedback; and

• Measuring results.

Dissemination is one of the most impor tant elements of any Lessons Learned Program. It is essential t hat target groups be properly i dentified along as well as the

most efficient method for dissemination of in formation. While distribution by email may be the preferred method to get Lessons Learned to management levels of the organization, it will not work well for non-management employees who do not have convenient access to computers. In t he latter case, posting the information on a bulletin board in their work center, includi ng a pre-shift/post-shift briefing or safety meeting may be the most appropriate method.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 32 When disseminating Lessons Learned, it is beneficial to keep the form of that document relatively standard so that the info rmation is easily assimilated by the target

audience time after time. The document (paper or electronic) will state:

• The purpose of distributing the Lesson Learned (intended for use in future safety meetings, provide immediate in formation to employees to prevent reoccurrence, inform employees of innovat ions allowing them to work safer;

• The source of the Lesson Learned (acci dent/incident review, submitted Lesson Learned, etc.);

• What Happened (a short, simple summary of the accident/incident, submitted Lesson Learned, etc.);

• What went right (stating positive thi ngs provides reinforcement for actions);

• What was learned (where did things go wrong);

• Recommended Corrective Actions or How to Prevent Reoccurrence (recommendations to prevent reoccurrenc e to include target dates for any necessary actions and the responsible individual or office for each); and

• Consideration should also be given to adding a section on Best Work Practices (a list of incident related best practices that will reinforce positive work habits) and providing contacts wher e the reader can get help or more information (Supervisor, SMS Coordinator, Safety Offi ce, etc.). Note: When it comes to

Recommended Corrective Action or How to Prevent Reoccurrence, a restating or paraphrasing an existing policy, process, procedure, etc. is inadequate and does not qualify as a legitimate Lesson Learned.

The Department of Aviation currently oper ates a Lessons Learned Program through

use of accident or incident reviews at Sa fety Committee Meetings and posting of accident/incident reports on Safety Bulletin B oards that contain the essential elements of a Lessons Learned Program (root cause, contributing factors and recommendations). The inclus ion of Airfield SMS relat ed Lessons Learned on these bulletin boards in appropriate work cent ers will be an effective and economical means of getting SMS Lessons Learned to those w ho need this information, but do not have convenient access to a computer. In a si milar manner, the addition of SMS Lessons Learned to the agendas of the airfield related Safety Committee Meetings will provide an efficient means of disseminating this information to co mmittee members and generating committee discussion/f eedback. Relevant Less ons Learned will be given in appropriate employee training courses. In this way, a Lesson Learned becomes a longer term tool to improve safety.

Efficiently soliciting Lessons Learned or fe edback on published Lesso ns Learned from

airfield stakeholders will be established. Sa fety Reporting forms, which are normally readily available to airport employees and many non-employees a like, will provide a simple, readily available means for an indi vidual to report a less on learned input or

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 33 provide feedback on a publicized Lesson Learned. It is essential that Lessons Learned Program performance indicators be identified and monitored. Those

indicators for ABIA are:

• Number of Lessons Le arned provided compared to the number disseminated;

• Number of Lessons Learned implementi ng actions completed within original target date compared to total implemented actions;

• Number of repeat incident s previously discussed in Lessons Learned compared to the total number of incidents;

• Number of repeat incident s previously discussed in Lessons Learned compared

to the total number of Le ssons Learned distributed; and

• Total number of Lessons Learned generated by management compared to the total generated.

For a Lessons Learned Program to be successful, the following points must be kept in

mind. Lessons Learned:

• Must be kept simple;

• Need management support at all levels;

• Need to involve every affected person (organizations and individuals);

• Distribution must be tailored in terms of target audience(s) and method(s);

• Needs a process to receive feedback;

• Performance needs to be measured; and

• May not produce 100% success .

6.6.2 Lessons Learned Prog ram Implementation

The Department of Aviation will implement a Lessons Lear ned Program that provides a simple process to identify knowledge that would be of benefit to an organization

and/or the individuals within it, disseminate that knowle dge to the appropriate groups, accept feedback and measure program effe ctiveness. To implement our Lessons Learned Program, the followi ng will be accomplished:

• The SMS Coordinator will be the responsib le individual to review, evaluate, and

disseminate Lessons Learned and measur e program effectiveness through the
establishment and tracking of appr opriate performance indicators;

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 34 • Make Lessons Learned a fundamental element of any after-project/after
incident review activity;

• Include appropriate Lessons Learned in appropriate employee training courses;

• Expand the Airport Safety Office Haza rd Reporting Form to include Lessons
Learned reporting;

• Allow SMS Lessons Learned information to be included on the Safety Office
Bulletin Boards in appr opriate work centers;

• Include SMS Lessons Learned as a standard agenda item for all meetings of
safety committees involvin g airfield stakeholders; and

Establish and track appropria te performance indicators to measure effectiveness of the Lessons Learned Program.

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 35 

### 7.0 NON-PUNITIVE REPORTING SYSTEM

In 1992, the FAA developed the Aviation Safety Action Program (ASAP) found in Advisory Circular (AC) 120.66b, for pilo ts and aircraft maintenance personnel at selected air carriers. The pr ogram has been a remarkable success, and has exceeded the goal of a confidential safety reporting syst em. Non-punitive reporting is an integral segment of the Safety Management System (SMS) and has been implemented in the FAA Air Traffic Organization (ATO). A non-punitive reporting system is a fundamental component of SMS.

The benefits of a non-punitive reporting system are:

• Provides strong incentives to report safety concerns;

• Establishes direct-line communications of safety informati on to managers;

• Reveals a more accurate view of airport operations safety issues.

• Reporting is confidential wit hout fear of reprisal; and

• Builds mutual trust between management and employees;

To create an open culture with safety excelle nce in the forefront, organizations must avoid an overly punitive reaction to even ts and errors. The employee must be encouraged to report errors without fear of recrimination. This will lead to learning opportunities and embracing changes for promotion of the ov erall safety at ABIA. A strong safety culture is one that reinforces accountability across all levels of the organization. It is a system of accountabi lity that does NOT focus on the human error or the unintended consequences but rather focuses on the quality of our decision making process.

7.1 Non-Punitive Reporting Process

Department of Aviation employees are expe cted to report any event or observation they feel represents a potentia l hazard. All Safety Reports shall be submitted to the SMS Coordinator for processing as described in Section 5.6, Safety Risk Reporting.

The specific components of t he non-punitive reporting systems may vary. Initially, the implementation of general gui delines will establish a foundation for a successful

program.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 36 7.2 Policy Statement

The Department of Aviation will establish a policy that identifies the elements of the non-punitive reporting program. It should include the means and method for reporting potential or real safety issues; time limit s for reporting; and under what circumstances the non-punitive reporting progr am would not apply.

7.3 Reporting Time Frame

The time frame for reporting a hazardous si tuation should be as soon as possible but should not to exceed a reasonable time peri od from the time the submitter becomes

aware of a hazard.

7.4 Types of Reports

The report of an unsafe or hazar dous situation may be made orally or in writing. If the hazard represents an imminent risk or a severe safety concern, immediate notification to the proper authorities is expected.

7.5 Tracking

The SMS Coordinator will track non-punitive r eports in accordance with established policies until the risk has been mitigated or accepted.

7.6 Non Qualifying Reports

Reports that involve criminal activity, subs tance abuse, intentional disregard for rules and regulations or falsification will be referred to the appropr iate supervisor for further handling.

The qualification process will be determined through a panel consisting of some or all of the following subject matt er experts as appropriate;

• Law Enforcement

• Fire Safety / ARFF

• Human Resource

• Operations

• Maintenance

• SMS Coordinator

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 37 

### 8.0 SAFETY PROMOTION

8.1 Culture

The main goal of safety promotion is to cr eate a “safety culture” that allows SMS to succeed. Culture is managemen t’s representation of what the organization believes and practices. Safety is a collective co mmitment that, with the proper implementation, places the responsibility for safety in the hands of every employee. The result is an environment that encourages t he identification, reporting, and correction of safety issues at every level.

The safety culture of the Depa rtment of Aviation is defi ned as a product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior. Culture is relatively stable, endur ing, and resistant to change.

Organizations that wish to create a positive and effective Safety Culture must have organizational values and beliefs are shared by all. The e ssential values in a positive and effective safety culture include int egrity, honesty, initiative, innovation, responsibility, openness in sharing information, and commitment to constant improvement and continuous learning.

An organization with these values will prov ide an environment w here the employee’s sense of self is woven into the organizati on’s values, and where the employees feel they are “a part” of something im portant, good, and larger than self.

8.2 Training & Education

8.2.1 SMS Training and Development

The success of any program is measured by the su ccess of its training and educational expertise. All Department of Av iation employees will be provided with a clear understanding of SMS policies and proc edures to perform their duties safely.

Training is the cornerstone of the Depart ment of Aviation safety and accident prevention program. All divi sion managers are responsibl e for developing personnel training programs that ensure adherence to the policies and procedures within their areas of responsibility and that are properly aligned fo r the skills and competencies necessary for each person to perform their duties in an effective and safe manner. Division Supervisors and above are responsible for continued dev elopment of training programs that address changes to the organizations policies, goals, and objectives.

Training programs include the process by which an assessment of potential hazards related to an employee’s job descriptions might be revealed. The commitment to train all employees, regardless of their professi onal discipline, is an indication of the Department of Aviation’s dedication to implement Safety Management System.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 38 Division Managers will review its safety and tr aining, periodically, to identify problem areas, determine specific safety objecti ves and re-develop coordinated, focused training programs.

8.2.2 SMS Coordinator

The SMS Coordinator will work with each Div ision Manager to ident ify SMS-specific training needs and, to the extend practical, the delivery of training sessions. To achieve that objective, training programs will be developed by:

• Identifying the jobs and t he tasks associated with each job, and determining the related knowledge and skills requir ed to safely perform those tasks;

• Defining the training objectives and t he methods by which training will be delivered, and designing test items and te sting methods to establish whether training objectives have been met; and

• Establishing the sequence in which the training topics will be presented, development of lesson plans, developm ent and assembly of training manuals, gathering all required training materi als, and assigning instructors.

8.2.3 SMS Training Evaluation

The effectiveness of training programs will be evaluated through:

• Post-training evaluatio n questionnaires; and

• Surveys of the effectiveness of trai ning programs with randomly selected participants.

The SMS Coordinator will assist managers with this training evaluation process, and

will maintain a central database of this effort for future consultations.

8.2.4 SMS Training Records

To insure responsible safety managemen t, formal documentation is required to provide the authoritative basis for the SMS. Personnel training records must be updated within two weeks of the training being completed and is the oversight responsibility of the SMS Coordinator. Tr aining records will be retained in accordance with Department of Aviation polic ies. Each Division Manager is responsible for sending safety related training records to the SMS Coordinator by the first of each month.

8.2.5 SMS Indoctrination Training Programs

All new Department of Aviati on employees will complete SM S Indoctrination Training, as may be directed by the SMS Coordinator, during their probationary period. This indoctrination training includes safety management program policies and procedures

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 39 as well as individual responsibilities and acc ountabilities related to SMS. This training will include, but not be limited to:

• SMS policies and procedures;

• Safety Risk Management (SRM) risk assessment and hazard recognition;

• Safety Report filing procedures; and

• Non-punitive safety reporting policy and guidelines.

SMS Recurrent Training will be provided to each employ ee on an annual basis. Recurrent training materials will include “les sons learned” from previous SRM studies and SRMD filings.

SMS recurrent training will em phasize on the job awareness of job-specific safety hazards. It will cover at a minimum the following:

• Changes to policies, procedures, rules, and regulations;

• On the job hazards;

• Equipment and environmental safety procedures;

• Safety Reporting Protocols;

• Roles of key safety personnel;

• SMS communications and shar ing of information; and

• Changes to Emergency Preparedness Plans.

Training programs will be updated when unfo reseen or unexpected circumstances dictate, such as the results of an SRM process due to changes of equipment, procedures, physical property, and/or personnel.

8.3 Organizational Development

Organizational Development is a systemat ic process to optimize individual and organizational performance, is essential for SMS success. It consists of two major
components:

• Leader Development; and

• Strategic Planning.

8.3.1 Leadership Development

Leadership Development is the continuous and deliberate proce ss of developing leadership skills, knowledge, and behaviors

. Quality leaders do not happen by

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 40 accident. Leadership is an observable set of skills and abilities that can be learned

and fine tuned over a time. Skilled leaders:

• Model the Way

- They are admired, respected and trusted because they :

o Share sacrifices and risks;

o Set the moral and ethical standard; and

o Establish caring relationships with those they work with.

• Inspire a Shared Vision

o Clearly articulate the vision;

o Demonstrate commitment to the vision; and

o Inspire and show ent husiasm and optimism.

• Challenge the Process

o Stimulate & encourage innovation;

o Allow subordinates to question assumptions; and

o Mistakes are part of the learning process.

•

• Encourage & Enable others to Act

o Personalized interaction;

o Provide new learning experiences; and

o Leadership by “Walking around”.

The above describes attributes of leadersh ip. How do you propose that Leadership Development be performed in the organization?

8.3.2 SMS Strategic Planning

Strategic Planning involves purposeful long term planning and attention to:

• Identification of SM S Mission, Vision, Values, and Key Functions;

• Aligning of Internal Processes with Key Functions;

• Developing metrics to proactively rate performance of Key Functions and Internal Processes; and

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 41 • Incorporation of SMS Leader Development as a critical component for implementation.

Leader Development and Strategi c Planning are integral to a viable and robust SMS Program. Management must show true commitment to:

• Safety as #1 priority;

• Full Implementation of SMS;

• Continuous safety Improvement;

• Culture of openness and initiative; and

• Providing necessary resources.

These actions must be factored into leader development and strat egic planning of the organization in order to ensure leaders cr eate and commit to the values of a quality safety culture.

8.4 SMS Management Awareness

The Department of Aviation will dev elop safety management awareness and understanding throughout t he entire organization communicating through:

• Safety seminars;

• Safety newsletters, notices and bulletins;

• Communicating safety lessons-learned;

• Bulletin boards and electronic reporti ng through email and a SMS website; and

• Safety campaigns on specific SM S issues identifi ed and emphasized.

Supervisors will further educate themselves through specific a SM S training program

that includes:

• Risk management;

• Accident/Incident investigation;

• Audits; and

• Performance measurement.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 42 8.5 Communications

The Department of Aviation management encourages a free and open exchange of safety information across all levels of employees and between all departments. Keeping staff informed about current safety issues through relevant training, safety literature, participation in safety courses and seminars, etc. improves the safety health of the organization. Departmental managers, in cooperat ion with the SMS Coordinator, are to encourage interdepa rtmental discussions on common safety issues, whether in the planning of activities or in response to safety reports or

concerns.

Employees are encouraged to bring up safety issues with their supervisor. The discouragement of safety r eporting and communication, whether tacit or explicit, will

not be tolerated. The SMS Coordinator will develop and coordinate an internal communication strategy aim ed at promoting safety and the safe conduct of all Department of Aviation activities. In addition to written communicati ons, it is important for employees to witness evidence of the commitment of top management to safety.

All supervisors shall actively and demonst ratively support the internal safety communication strategy. The safety communi cation strategy should include, for example:

• Safety bulletin boards;

• Safety newsletters;

• Safety posters;

• Safety awards, recognitions;

• Safety events and

• Stakeholder meetings.

8.6 Safety Incentive Programs and Events

The Department of Aviation shall establish various ince ntive programs designed to recognize an employee’s special effort to im prove or enhance the or ganizations safety

culture. The SMS Coordinat or will oversee the development of programs that support the promotion of safety. The nature of these programs shall be defined and communicated to the ABIA community as they become available.

Safety incentive events such as safety stand-downs, safety fairs, and safety campaigns will be aimed at promoting safe ty and encouraging empl oyee participation.

The SMS Coordinator will endeav or to arrange these kinds of activities on a quarterly basis, and will seek the cooperation and partici pation of external stake-holders.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 43 8.7 Safety Promotion and Training Checklist Summary

• Management recognizes that all levels of the organization r equire training in safety management and that the needs vary across the organization;

• Job descriptions reflect competency requirements;

• All personnel receive safety indoctrinat ion training and partici pate in specific ongoing training for safety management;

• The organization has an effective program for the timely promotion of safety issues;

• Additional safety awareness traini ng is provided when the operating environment changes (seasonal chan ges and changes in operational conditions, regulatory r equirements, etc.; and

• Employees understand that safety management has nothing to do with attributing blame.

8.9 Safety Council

Safety Council’s are vitally important to the organization by allowing discussion, input, and disagreements on safety performance and promotion to be voiced from various departments, tenants, ai rlines, and other interested parties. Membership should consist of representatives from both Departm ent of Aviation staff and Airport tenants to provide a forum to discuss safe ty issues, policies, and pr ocedures, both current and proposed.

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 44 

### 9.0 SMS PROGRAM IMPLEMENTATION

The implementation of a Safety Management System into an organization will not be accomplished overnight. A well thought-out impl ementation plan will help ensure the programs’ success, while not over burdening the organization’s human and financial

resources.

10.1 Department of Aviation Implementation Approach

The implementation of the Department of Aviation SM S Program will be a phased approach, starting with the Operations and Maintenance Divisions. These two organizations will implement SM S into their organizations first. As SMS knowledge, skills and abilities are mastered, additional SMS features and organizations will be

added.

The Department of Aviation plans to expand SMS to other depar tments and Airport stakeholders as the program matures. This expansi on may require additional resources and financial planning on the part of management to experience the full benefit of an improved safety culture.

10.2 SMS Staffing Requirements

All start-up programs, such as implementing SMS Program, can require a significant amount of an organizations time. The assistance of the SMS consultant has provided Department of Aviation a running start in the programs development and implementation. To ensure the programs success, the De partment of Aviation will be required to devote the required resources to accomplish the SMS Coordinators’ role in the organization.

10.3 Financial Implementation of the Department of Aviation SMS Program

The Department of Aviation’s goal is to implement t he SMS Program with existing staffing and resources. Eventually, SMS staffing support and res ources are expected to grow as the program matu res. Ultimately, the Department of Aviation community should have a SMS specialist, who’s res ponsibility is to sustain a continued improvement in the safety culture by reduc ing the risk of accidents and incidents. Staffing a SMS professional (Department of Aviation or contract employee) is expected to cost $85,000.00 annually.

Additionally, the implementati on and integration of software applications and hardware to measure performance metric criteria will also benefit the goal of long term success. Technology support for implem enting SMS will require softw are applications, software development for databases, hardware and in tegration support. These technology support elements are planned to be a one-time expense, but should not exceed a capital investment betw een $150,000 and $200,000. Software programs and support

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 45 may also be a phased-in approach as pe rformance measures and trend analysis

activities become more defined.

10.4 Implementation Guidelines

The following list of implementation activi ties have been developed for the ABIA SMS Program implementation. These activities will provide a scheduled detailed sequential approach toward building the Safety Cu lture, employee Knowledge Base, and Confidence with implementing SMS.

Those activities are as follows;

Year One, First Quarter

1. Publish an organizational chart identif ying positions and safety responsibilities
of all key personnel.

2. Appoint the ABIA SMS Coordinator as the primary point of contact for all
matters related to the implementati on of SMS, maintenance of the SMS
Handbook, and SMS training

3. Publish safety policy statement a nd describe how it is communicated to
Department of Aviation employees.

4. Identify, describe, and recommend airport safety objectives.

5. Communicate to all Airport tenants the Safety Policy and Objectives, and
commitment to SMS and improving the sa fety culture of the organization.
Communicating feedback to staff and perso nnel can be accomplished through:

• Safety recognition and/or awards programs

• Staff meetings

• Bulletin boards

• Newsletters

• Computer briefings at sign-in

• E-mails to personnel

6. Provide SMS Overview and Safety Risk Management training to all Department

of Aviation Operations and Maintenance employees.

7. Develop Initial trend analysis models.

8. Create self-inspection findi ngs performance metrics.

9. Prepare recommendations for developing the databases, models, and analytical
tools to be used for risk management.

10. Document process to identify tr aining requirements for systems safety.

11. Identify or develop plan to validat e training effectiveness and the process to
gain training feedback, including useable metrics.

12. Identify or develop de fined processes to communicate safety policies and
objective throughout the organization.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 46 13. Develop process for document ing and storing results of SRM.

14. Describe how existing quality and risk management activities will be integrated

into the SMS.

15. Conduct training and education, safe ty communication, competency, and
continuous improvement processes.

Year One, Second Quarter

1. Implement a plan for employee SMS or ientation and training with outline of
proposed curriculum and resources.

2. Implement how top managem ent will follow-up on SRM to ensure risk mitigation
strategies are appropriate.

3. Establish self-auditing processes.

4. Develop strategic plan to integrate the tailored SMS program into the overall
operation of the airport.

5. Develop Final SMS Plan and Sch edule for implementation along with
anticipated costs.

6. Establish Safety Council to provide peer review of safety reports, hazard
analysis, and safety communication.

7. Develop a plan to integrate apron safety management into the SMS.

8. Distribute copies of SMS Hand Book to Department of Aviation supervisors and

tenant management

Year One, Third Quarter

1. Initiate lessons learned safety assurance program.

2. Publish the Department of Aviation Dir ective that formally establishes the
systematic business processes for the identification of hazards and the
analysis, assessment, and mitigation of safety risks.

• Describe the system, proc edure, and/or organization

• Hazard identification

• Analyze the risk

• Assess the risk

• Mitigate the risk

3. Establish Safety Performance Indicators to act as a benchmark for analysis of
future improvements in safety culture.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 47 Year One, Forth Quarter

1. Conduct internal audits of hazard assessments, risk analysis, and safety
performance indicators.

• Ensure planned remedial action s of a risk have been implemented

• Monitor the effectiveness of the mitigation

• Consider the future re levance of the mitigation

• Establish an audit/assessment checklist with planned reviews

2. Create a high level Monthly Safety R eport for the Department of Aviation.

Year 2, First Quarter

1. Conduct recurrent training of objectives and procedures.

2. Updated training materials to ensur e employees know and comply with new
safety requirements associated with their job and within the organization

• Safety Risk Management Decisions

• Human Factors

• Team Building

• Reaffirm understanding of SMS and its re levance to employees, to their
positions and to the culture of the organization

Year Two, Second Quarter

1. Review performance indicators and the dat a to support them to ensure they are
evolving into areas that more fully evaluate system effectiveness

• Indicators that better identify areas of weakness so that efforts can be
properly focused.

• Indicators that are more Global in nature.

• Indicators that have matured, becoming increasingly relevant to workforce

selected issues.

2. Initiate a Employee Safety Survey to compare the results of the first survey
accomplished in August of 2008. Meas ure any perceived safety culture
changes and re-set targets as needed.

3. Synthesize the following leading indi cators for analyzing Aviation safety

program

• The degree of commitment to health and safety

• How highly both management and workers value a safe workplace

• The level of awareness that work ers and management have of job related

risks

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 48 • Whether inspection and preventative maintenance programs are followed

• The level/quantity of training provided

• Total hours of training provided

• The degree of activity of Safety Committees

Year Two, Third Quarter

• Initiate a Department of Aviation Po licy for a Non-punitive safety reporting
system applicable to all Depar tment of Aviation employees

• Identify the elements of the Volunt eer Safety Reporti ng program

• Describe methods for filing safety reports;

o Recipients of the report – who within the organization gets the report and

what is done with the information

o Time limits for reporting - reporti ng a hazardous situation as soon as
possible but not to exceed 24 hours fr om the time the submitter becomes

aware of a hazard

o Under what circumstances the non- punitive reporting program would not
apply – intentional acts, negligence, criminal behavior

o Types of Reports - orally or in writing,

o Safety Committee Review – perform SRM, implement corrective actions
if applicable

o Disseminate all factors to those who have a need to know.

o Tracking progress of the correct ive actions until the hazard has been
eliminated to the fullest extent possible

o Non qualifying reports that appear to involve criminal activity, substance
abuse, intentional disregard for rules and regulations or falsification will
be referred to the appropriate office for further handling.

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 49 

### 11.0 APPENDICES

The following is a list of included Appendices;



### Appendix 1 - Definitions

Appendix 2 - Human Factors

Appendix 3 - Performance Indicators

Appendix 4 - The 21 Elements of SMS

Appendix 5 - Safety Risk Management Document Report

Appendix 6 – SRMDR Supplemental hazard Analysis Worksheet

Appendix 7 - Forms

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 50 

### Appendix 1 - Definitions

Acceptable level of risk – risk determined by management that has been reduced to a level that can be accepted by the organ ization after considering all safety and legal obligations.

Accident – An unplanned event or series of event s that results in death, injury or damage to, or loss of, equipment or property.

Apron (Ramp) – an area on an airport prepared for the purpose of providing aircraft with parking space for the embarkation and disembarkation of passengers, the loading or unloading of mail or carg o, aircraft servicing, or undergoing

maintenance.

Audit – Objective assessments to evaluate conformity with policy, standards and contractual requirements. Internal audits are conducted within the department or organization and external audits can be conducted by regulatory offices or contractually through an outside vendor.

Best Practice – Method or procedure recognized by industry as being operationally effective in achieving stated objectives.

Cause – A reason, condition, task, or activity that brings about a hazardous act or

state.

Comments – Notes, implementation or time line requirements or other pertinent

information.

Corrective Action – A change implemented to address a weakness identified in a system, normally a management system.

Current Risk – Level of risk attributed to the hazar d. (High, Moderately High, Medium, Low)

Description – A word depiction of the real or perceived hazard.

Existing Control – System, process, procedure, or po licy currently in place to counter

the hazard.

Gap Analysis – Identification of existing sa fety components, compared to SMS program requirements. Gap analysis provides an operat or an initial SMS development plan and roadmap for compliance.

Hazard – Any existing or potential condition that can lead to injury, illness or death to people; damage to or loss of a system, eq uipment or property; or damage to the

environment. A hazard is a condition that is a prerequisite to an accident or

incident.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 51 Incident – An event that has the pot ential to lead to an accident.

Indicators, leading & trailing or lagging – leading indicators are predictors of future safety performance based on selected criteria. Trailing or lagging indicators are afterthe-fact measures of safety performance.

Lessons Learned - Knowledge acquired fr om an innovation or an adverse experience that causes a worker or an organization to improve a process or activity to work safer, more efficiently or with higher quality.

Likelihood – The estimated probability or frequen cy, in quantitative or qualitative terms, of a hazard’s effect. The frequency or regularity in which the hazard can occur, (frequent, probabl e, remote, improbable).

Oversight – A function that ensures the effect ive promulgation and implementation of safety standards, requirements, regul ations and associated procedures.

Quality Assurance – planned and systematic actions necessary to provide adequate confidence that a product or service will sa tisfy given requirements for safety and quality.

Potential Effect – The effect(s) the hazard woul d have on the system state if not mitigated.

Records – Evidence of results achieved and activi ties performed. In this context, they

are distinct from documentat ion as what is written is permanent and does not change

over time.

Recommended Safety Mitigation – Additional procedures, actions, activities or processes imposed on the system state to lessen the like lihood and/or seriousness of

the hazard.

Residual Risk – A re-measuring of the risk level once recommended safety mitigations are implemented.

Risk – the consequence of accepting a hazard.

Risk Assessment – process for evaluating the le vel of risk and comparing whether the analyzed risk level and the acceptable risk level is tolerable.

Safety – The condition to which environment, health, occupational and aviation risks are managed to acceptable levels.

Safety Assessment – A systematic and comprehensive evaluation of an implemented system to see if all safety requirements are met

Safety Assurance – SMS process management functions that systematically provide

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 52 confidence that organizational products/services meet or exceed safety requirements.

Safety Culture – The product of individual and gr oup values, attitudes, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, the organization's management of safety. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the impor tance of safety, and by conf idence in the efficacy of preventive measures.

Safety Management System (SMS) – The formal, top-down business-like approach to managing safety risk. It includes syst ematic procedures, practices, and policies for the management of safety (including safety risk management, safety policy, safety assurance, and safety promotion).

Safety Objective – Safety goals or desired outco mes, which are measurable.

Safety Policy – Defines the fundamental approach to managing safety that is to be adopted within an organization. Safety polic y further defines the organization’s commitment to safety and ov erall safety vision.

Safety Promotion – A combination of safety cult ure, training, and data sharing activities that support the implementation and operation of an SMS in an organization

Safety Risk – The composite of predicted severi ty and likelihood of the occurrence defines the potential effect of a hazard.

Safety Risk Control – Any action that miti gates the safety risk of a hazard. Safety Risk Controls necessary to mitigate an unacceptable risk sh ould be mandatory, written in requirements language, m easurable, and monitored to ensure effectiveness.

Safety Risk Panel (SRP) – The SRP will consist of Av iation Department subject matter experts, either direct ly or indirectly involved with the change and as required, and representatives of airlines, concessiona ires, or other ABIA tenants (external to Aviation Department employees) for their expertise and counsel, as appropriate. The

involvement of these resour ces will help ensure that all aspects and consideration have been explored, debat ed, assessed, analyzed, and mi tigated. A SRP will be sized for the specific safety issue presented and ma y consist of from 3 to 25 members. The

SMS Coordinator will determine the level of participation required.

Safety Risk Management (SRM) – A formal process withi n the SMS composed of describing the system, identifyi ng the hazards, assessing the risk, analyzing the risk, and controlling the risk. The SRM process is embedded in the o perational system; is not a separate/distinct process.

Safety Risk Management D ecision Report (SRMDR) – The SRMDR is the primary SMS report that will be complet ed for every assessment regardless of the complexity. This report must be retained for trend and dat a analysis. If subsequent or additional assessment is required for the same subjec t, then the subsequent SRMDR will be filed

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 53 with the previous report.

Self-Assessment Plan – A formal, management-approved document that describes an airport operator’s self-assessment activiti es and how often they occur, provides a schedule for completing the assessments, and identifies the reports to be generated.

Serious Injury– an injury which is sustained by a person in an accident and which: (1) requires hospitalization; (2) results in a fracture of any bone; (3) involves

lacerations which cause severe hemorr hage, nerve, muscle or tendon damage; (4) involves injury to any internal organ; (5) in volves second or third degree burns on more than 5% of the body; (6) involves harmful exposure to radiation.

Severity – The consequence or impact of a hazard in terms of degree of loss or harm.

The level or extent to which property damage, injury or lo ss of life is contributable to a hazard. (Catastrophic, Major, Minor, Minimal)

SMS Output – The result or product of an SMS process; in this context, it is the result of a process, which is intend ed to meet a requirement describ ed in this Manual (e.g. results of safety risk analyses, safety audi ts, safety investigations, and trend analysis of safety performance indicators).

Supplemental Hazard Analysis Worksheet – This worksheet is utilized to assist teams assessing hazards by documenting their approach, assumptions, and findings. These worksheets should be kept with the Safety Risk Management Decision Report (SRMDR) as back-up material, if needed at a later date for such things as audits or investigations.

System(s) – An integrated set of elements that are combi ned in an operational or support environment to accomplish a defi ned objective. These elements include people, hardware, software, firmware, informa tion, procedures, facilities, services and

environment.

System State – The state of a system (or partic ular environment) and refers to that environment/system's condition at a particula r moment in time or under certain conditions. The current configuration, poli cy, procedure, or proc ess from within which

the hazard exists.

Top Management – The person or group of people that directs and controls an organization. Sometimes it is also referred to as senior management

Tracking Number - A unique number assigned each hazard for the purpose of referencing the hazard during the analysis.

Trigger Mechanisms - Environmental component t hat causes or enhances the probability of a hazard to occu r. Trigger mechanisms incl ude (but are not limited to):

• Personnel Quality issues : aptitude, skill, experience, or training,

• Manpower issues: The number of people available to operate and maintain systems and procedures;

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 54 • Weather conditions (rain, snow, ice, wind, etc),

• Fatigue

,

• Distractions

,

• Stress

,

• Equipment failures or use issues

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Jacobs Carter Burgess Safety Management System Team, October 2008 Page 55 

### Appendix 2 – Human Factors

Human Factors (HF) is the ar ea of study that seeks to maximize the relationship between people and systems in or der to improve performance, safety, and reliability. Systems include equipment, procedures, or organizations or teams. Purposely integrating HF into SMS creates a bedrock foundation fo r successful and continuous safety improvement. HF integration into SMS involves the overlap and interaction of

three factors:

• People

• Equipment

• Organizations

PEOPLE : By taking advantage of what we know about how people process

information and interact with each other we can better design the systems that we use in the workplace. Different aspects of human information processing include:

• Perception (seeing, hearing, etc)

• Attention and mental workloads (fatigue can play a crucial role)

• Memory (fatigue plays a role here too)

• Problem-solving and decision-making

• Communication:

o Between individuals

o Within and across groups

• Social interaction factors (sharing info or reluctance to share info)

For example, read the following sentence in Figure 5.1 and count the number of letter

F’s seen:

“FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY

COMBINED WITH THE EXPERIENCE OF YEARS.”

Figure 1, Perceptual Example No. 1

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 56 Many hundreds of people who r ead this sentence for the firs t time miss several of the “F’s”. The F’s are all there, right in front of their eyes, but they just don’t see them.

For those who have seen this sentence before , it’s harder to “tri ck” the brain, they usually spot all the F’s right away. There are several theories as to why this happens which involve how the brain processes vis ual (and other sensory) information. The simple fact of the matter is that sometimes you just can’t see what’s right in front of

you . (There are six F’s in the above sentence.)

The implication for HF within SMS is to ensure that people within the organization always try to view operations and proc edures from another vantage point. After the fact, it is quite easy to see that a dangerous procedure or situation was allowed to exist, but oftentimes, befor ehand, it was not that notic eable. The saying goes something like this, “You can’t see the forest, for the trees.”

Sometimes perceptual processes cause us to “see” something

that’s not there. Figure 5.2 provides a simple example of a perceptual process. When look ing at the graphic depicted in Figure 5.2 a defined, very bright whit e triangle may appear to float above the page. Is there r eally a white triangle floating above the page? Of cour se not, but....it does seem to be

there.

As illustrated by these two perceptual examples....

“Sometimes we don’t see what’s there, and other times, we see something that isn’t

there!!!”

Personnel need to be on the lookout for the “F’s we can’t see” and the issues we think are perfectly fine, but just an illusion. HF concepts that deal with how people process both sensory, attention, and interpersonal communicati on information can be subtle and hard to pinpoint, however, awareness and vigilance is key in identifying these

factors that can contribut e to safety degradation.

Two other People issues in SMS must also be addressed. They include:

• Manpower : The number of people available to operate and maintain systems and procedures

• Personnel Quality : Aptitude, skill, experience, training, and other characteristics necessary to optimize safety and performance

These “People” issues have significant a ffects on the SMS. Sk illed, high quality personnel, trained properly, in the right num bers, are key to high system safety. Figure 2, What Do You See 

### ?

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 57 Equipment : The design of equipment or proc edures on how to use equipment, may also have significant impact system safety. An equipment system may be as simple as a radio or as complex as an Ai r Traffic Control Tower. Awareness of the HF issues involved in the equipment used by an organi zation, especially new equipment, is critical in identifying issues that may be degrading safety before these issues actually result in a safety incident.

For example, perhaps an older model vehicl e used in operations has a history of popping out of gear when in “park”. New vehi cles cannot be purchased until the next fiscal year. It is known that as long as the emergency brake is employed, the vehicle is safely parked. Awareness of this safety issue can influence daily briefings, safety updates, training, and preventiv e maintenance inspections by users and mechanics. A general “awareness” across dep artment “systems” helps guarantee, employees will be vigilant when parking this v ehicle or maintaining it.

Organizations : Organizations are also systems. Different department s, divisions, offices, crews, and tenant organi zations all work and interact together. Each develops and operates under many policies and procedures, some shared, and some individual for each particular group.

HF plays a role when procedures from one group are unknown or unclear to the others, and can have detrimental affects on overall safe operations. The more procedures and policy knowledge is shar ed and understood across and within groups, the greater the awareness and vigilance for procedural fact ors that might have serious safety implications.

In conclusion, SMS and Human Factors are inextricabl y linked. It is important to be vigilant in the detection of system “design” vulnerabilities, whether that system is a piece of equipment, a procedure, or crew or staff working together. Personnel must continuously monitor for system parameters at “critical ma ss”, i.e. fatigue, physical requirements, stressors, numbers and qua lity of personnel or equipment, and organizational issues (values, norms, climate, etc.). All of these factors can degrade safety climates slowly, but surely, if they are not identified and acti on taken in a timely

manner.

Employees at every level need

to monitor and

communicate safety issues

and concerns. They must be on

constant look

out for: “The alignment of

nature and circumstances that create pathways in which accidents may occur.” Figure 3, Swiss Cheese Multilayered Safety Model

Adapted from James Reason, the Reason Model

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 58 If one considers a working environment as a piece of Swiss cheese and the holes in the cheese line up, we allow circumstances to domino into a safety incident. The objective then is to keep the hol es of the Swiss cheese out of order. It is important not to allow easy pathways to develop, where one factor after another is allowed to exist and set up the environment for a safety incident.Appendix 3 – Performance IndicatorsTable 6.1Examples of Performance IndicatorsSMS Program Manual for ABIANo.Performance IndicatorSpecific MeasuresHow to MeasureResponsibility1Management’s VisibleParticipation in Safety•Employees’ perceptions of the effectiveness ofsafety visits to work centers by senior managersfrom employee surveys•Employees’ perceptions of managementcommitment to safety from employee surveysEmployee SurveysSMS CoordinatorSMS Coordinator2Senior Manager SafetyVisits•Number completed vs. number scheduled•Employees’ perception of their effectivenessEmployee SurveysSMS CoordinatorSMS Coordinator3Employees’ Understandingof SMS•Percent of correct answers on random follow-upsurvey 30 days following training and periodicallythereafterEmployee SurveysSMS Coordinator4Safety Committees•Effectiveness of safety committees (are they morethan a coffee break)•Number completed vs. number scheduledEmployee SurveysMeeting record(s)(e.g.sign-in sheet, meetingagenda)SMS Coordinator5Voluntary Safety HazardReporting•Number of submissions•Number of issues acted upon/closed by initialsuspense•Average time to closeSMSCoordinatorSMS CoordinatorSMS Coordinator6Voluntary LessonsLearned Reporting•Number of submissionsSMSCoordinator7Safety Audits•Number completed vs. number scheduledSMSCoordinatorABIA Safety Management System Program ManualTable 6.1Examples of Performance IndicatorsSMS Program Manual for ABIANo.Performance IndicatorSpecific MeasuresHow to MeasureResponsibility8Safety Surveys•Number completed vs. number scheduledSMSCoordinator9Safety Survey/AuditsFindings•Number closed by initial suspense•Average time to closeSMSCoordinatorSMS Coordinator10SMS TrainingNumber and/or percentage of personnel trained•Percent of correct answers on Random follow-upsurvey 30 days following trainingSMSCoordinatorSMS Coordinator11Ad Hoc Training (trainingresulting from SRMdecision reports, etc.)•Percentage of required individuals trained within 30days of establishing requirement.•Percent of correct answers on random follow-upsurvey 30 days following trainingSMSCoordinatorSMS Coordinator12Weekly Employee SafetyMeetings•Number conducted vs. number scheduled•Effectiveness of safety meetings from employeesurveys (are they more than a coffee break)Meeting record(s)(e.g.sign-in sheet, meetingagenda)Employee SurveysShift SupervisorSMS CoordinatorJacobs Carter Burgess Safety Management System Team, October 2008 Page60ABIA Safety Management System Program ManualJacobs Carter Burgess Safety Management System Team, October 2008 Page61Table 6.1Examples of Performance IndicatorsSMS Program Manual for ABIANo.Performance IndicatorSpecific MeasuresHow to MeasureResponsibility13Corrective Actions•Number of Part 139 discrepancies open beyond 30days. (It is no longer considered to be “routine” if adiscrepancy is open beyond 30 days.)•Percent of corrective actions that were closed on orbefore the target date.•Number of corrective actions that are still openbeyond original target date.•Average number of days beyond original target dateit took to close corrective actions.SMSCoordinatorSMS CoordinatorSMS CoordinatorSMS Coordinator14Lessons Learned•Number of Lessons Learned provided compared tothe number disseminated.•Number of Lessons Learned implementing actionscompleted within original target date compared tototal implemented actions.•Number of repeat incidents in Lessons Learnedcompared to the total number of incidents.•Number of repeat incidents in Lessons Learnedcompared to the total number of Lessons Learneddistributed.•Total number of Lessons Learned generated bymanagement compared to the total generated.SMSCoordinatorSMS CoordinatorSMS CoordinatorSMS CoordinatorSMS CoordinatorSource: Jacobs Carter Burgess Team, October 2008

### Appendix 4 - The Twenty-One Elements of SMS

The 21 Elements of a Safety Management System (SMS) are as follows:

1. A written safety policy statement and description of how it is communicated to airport employees.

2. Identification and description of the airport sa fety goals.

3. A plan for employee SMS indoctrinat ion and training. SMS indoctrination training should provide an outline of proposed curriculum and resources.

4. Documented process to identify training requirements for systems safety.

5. A plan to validate training effectiveness and the process to gain training feedback, including useable metrics.

6. A defined process to communicate safe ty policies and objectives throughout the organization. Include examples of how information will be communicated and any processes for follow-up.

7. A plan and description of employee non-punitive reporting systems, existing and planned.

8. An organizational chart identifying the names and safety responsibilities of all key personnel, such as the following:

• Top Management

• Safety Manager

• Managers and Supervisors

• Established Safety Committees and Chairpersons

9. Description of the sa fety risk management process, including application of “The Five Phases of SRM (safety ri sk management),” as discussed in AC 150/5200-37, Introduction to Safety Management Systems for Airport Operators.

10. Guidance on the use of SRM and trend analysis.

11. Defined process for documenting t he results of SRM Decision Reports (SRMDR), including a description of how documents will be stored, i.e., electronic or paper.

12. Description of how top management will follow up on SRMDR to ensure safety mitigation strategies are appropriate.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 63 13. A description of the airport quality management and/ or risk management program (if applicable) and its integration into the airport SMS.

14. Description of a plan to integrate apron safety management into the airport SMS. (The FAA’s review of the plan will be limited to measures for preventing accidents or incidents involving aircraft. ) The plan could include the following:

• A description of current apron safety management practices, such as reporting requirements to the Nati onal Transportation Safety Board (NTSB), Flight Standards, or t he Occupational Safety Health Administration (OSHA).

• An explanation of how current apr on safety management practices meet the intent of SMS. This could include the safety plans and practices of tenants and operators at the airport, which should complement the airport SMS.

15. A detailed method to doc ument self-auditing proce sses and their findings. Selfauditing may be part of the airport self-ins pection process. If it is, explain how the self-inspection process addresses systems safety, i.e. if the self-inspection program identifies a hazard on the air port it should determine the risk and document the process for follow-up.

16. A detailed method to doc ument self-inspection reviews, analysis, and findings.

17. A description or plan to integrate the ta ilored SMS program plan into the overall operation of the airport.

18. Documented plan for training and education, safety communication, competency, and continuous im provement processes.

19. Procedures to promote safety awareness and participation in non-punitive reporting systems.

20. Process to document and review lessons learned from within the organization.

21. Schedule for implementation and anticipated associated costs.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 64 

### Appendix 5 – Safety Risk Mana gement Decision Report (SRMDR)

1. Report Date: 9/11/2008

2. Current System, Procedure, or Activity:

3. Proposed Change:

4. Project, Re-configuration, Operation, Equipment, Task or Activity:

5. Hazard Identification (real or perceived):

6. Risk Analysis:

7. Trigger mechanisms:

8. Existing controls:

9. Human Factors:

10. Risk Assessment:

a. Severity:

b. Likelihood:

11. Mitigation and/or Trea tment of Risks:

12. Communications and Training Requirements:

13. Monitoring and Tracking Responsibility:

14. Safety Risk Management D ecision Report Approval

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 65 ABIA SMS Coordinator Approval Date

Is Director Level Approval Required? Yes / No

ABIA Director of Operations Approval Date

ABIA Director of Maintenance Approval Date

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 66 

### Appendix 6 - SRMDR Supplemental 

### Hazard Analysis Worksheet

(To be completed for 

### each identified hazard)

Date:

Hazard Tracking Number: Hazard Element Number:

Hazard Description:

Cause of Hazard:

System State:

Possible Effect:

Human Factors:

Existing Controls or Requirements:

Severity:

Severity Rational:

Likelihood:

Likelihood Rational:

Current/Initial Risk:

Recommended Mitigation:

Predicted Residual Risk:

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 67 Preliminary Hazard Analysis Worksheet Definitions

Tracking Number - A unique number assigned eac h hazard for the purpose of referencing the hazard during the analysis.

Description – A word depiction of the real or perceived hazard.

Cause – A reason, condition, task, or activi ty that brings about a hazardous act or

state.

System State – The current configuration, policy, procedure, or process from within

which the hazard exists.

Potential Effect – The effect(s) the hazard woul d have on the system state if not mitigated

Severity – The level or extent to which proper ty damage, injury or loss of life is contributable to a hazard. (Cat astrophic, Major, Minor, Minimal)

Existing Control – System, process, procedure, or po licy currently in place to counter

the hazard.

Likelihood – The frequency or regularity in which the hazard can occur. (Frequent, Probable, Remote, Improbable)

Current Risk – Level of risk attributed to the haz ard. (High, Moderat ely High, Medium, Low)

Recommended Safety Mitigation – Additional procedures, actions, activities or processes imposed on the system state to lessen the like lihood and/or seriousness of

the hazard.

Residual Risk – A re-measuring of the risk level once recommended safety mitigations are implemented.

Comments – Notes, implementation or time line requirements or other pertinent

information.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 68 Preliminary Hazard Analysis Worksheet

ID Description Cause

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 69 

### Appendix 7 - Forms

The following Forms are included in this SMS Manual;

o SAFETY RISK MANAGEMENT SMS COORDINATOR DOCUMENTATION

o SAFETY REPORTING FORM

o LESSON LEARNED REPORTING FORM

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 70 

### SAFETY RISK MANAGE MENT SMS COORDINA TOR DOCUMENTATION

Date Report Received: ______/______/______

Description of System – Procedur e – Equipment – Personnel_______________

______________________________________________________ _____________

Hazard/Risk identified as reported______________________________________

___________________________________________________________________

Hazard/Risk Assessed/Anal yzed___________________

____________________

______________________________________________________ _____________

Level of Risk Assessed as :_______________________

_____________________

Additional Risks associat ed with hazard? – Y/N___ List as separate documents

By Manager(s) / Titles: ______________

_______, _____________ ____________,

Change(s) Required? – Y/ N ____ If No, Manager Approval__________________

Change(s)/Action(s) Options__

__________________________ _______________

Mitigation Decision and Implem entation Plan_______

______________________

__________________________________________ ___________________________

______________________________________________________ ___________

Manager Approval __ _________________Title/Managem ent Level____________

Start Date Est.____________ ______ Completion Date Est.___________________

Entered in SRM Database?_____________

Communications - Y/N - SMS Coordinator Responsibility

FAA________ COA________ ABIA Divisio ns _________ Stakeholders___________

ATO________ Staff_______ Event Repor ter_______ Employees_____________

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 71 

### SAFETY REPORTING FORM

This form should be used to report any hazard or safety concern that has caused or

could cause an accident or inciden t. Send to the ABI A SMS Coordinator as soon as possible after the hazard has been recognized, identified, and/or ob served. Obviously, if the hazard is an emergency or severe sa fety concern, contact Operations and/or Director of Operations and Maintenance o ffice immediately and/or ABIA emergency

numbers – Include List - 911
EVENT DESCRIPTION (To be completed by person reporting the event)

DATE:___/____/____ TIME : ______________AM/PM

LOCATION:______________

____________________________________ _________

__________________________________________ ___________________________

DESCRIPTION: ____________________

_____________________ ______________

__________________________________________ ___________________________

__________________________________________ ___________________________

__________________________________________ ___________________________

__________________________________________ ___________________________

WEATHER CONDITIONS:__________

_____________________ ________________

(SMS Coordinator: Tear here and discard securely before processing)

Your Name_________________ ______ Division or Wo rk____________________

Group __________________________

Contact number ________________ E-mail address_______________________

Confidentiality Statement Providing your name can help the ABIA Safety process by allowing yourself to be contacted for additional details regarding the safety concern. Your name will be

known ONLY to the SMS Coordinator under t he policy agreed to by the ABIA

Executive Director and will NOT be released without your permission. You may also submit this reporting form anonymously by fil ling out the top secti on of the form with only the details of the event.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 72 

### LESSON LEARNED REPORTING FORM
(Sample)

A Lesson Learned is knowledge acquired from an innovation or an adverse experience that causes a worker or an organization to improve a process or activity to work safer, more efficiently or with higher quality.

This form should be used by anyone desiring to report an innovation or adverse experience that others can learn from or to comment on a previously published Lesson

Learned.

LESSON LEARNED DESCRIPTION (To be completed by person reporting the event)

DATE:___/____/____ TIME OF EVENT: ______________AM/PM

LOCATION:________________________________________________________________

WHAT HAPPENED or INNOVATION:________________________________________________

_______________

___________________________________________________________________________

______________________________

WHAT WENT RIGHT or ADVANTAGES:_______________________________________________

_______________

___________________________________________________________________________

______________________________

WHAT WAS LEARNED:

___________________________________________________________ ________________

____________________________________________

RECOMMENDATION or COMMENTS:_________________________________________________

_______________

_________________________________________________________________________ (use back of form if more space is needed)

........................................................................................................................... (SMS Coordinator: Tear here and discard securely before processing)

Your Name_______________________ Division or Work _______________________

Group ___________________________

Phone number ___________________ E-mail address ______________________

_

Confidentiality Statement Providing your name can help by allowing you to be contacted for additional details regarding

the Lesson Learned. Your name will be known ONLY to the SMS Coordinator under the policy agreed to by the ABIA Executive Director and will NOT be released without your permission. You may also submit this reporting form anonymously by filling out the top section only.

### ABIA Safety Management System Program Manual

Jacobs Carter Burgess Safety Management System Team, October 2008 Page 73 

### 12.0 LIST OF FIGURES

Figure 4.1 - Lines of Succession for Sa fety Management Systems (SMS) Page 12

Figure 5.2 - The SRM Life Cycle Page16

Figure 5.1 - Predictive Risk Matrix Page 17

Figure 5.2 – Likelihood Levels Page 18

Figure 5.3 – Severity Levels Page 18

Figure 7.1, ABIA Data Managem ent Page 25

Figure 1, Perceptual Example No. 1 Page 55

Figure 2, What Do You See? Page 56

Figure 3, Swiss Cheese Multilayered Safety Model Page 57