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PROTECTING DATA COLLECTED FOR SAFETY PURPOSES

ICJOURNALAO VOLUME 61 NUMBER 6, 2006

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ICAO Journal The magazine of the International Civil Aviation Organization THE ICAO COUNCIL VOL. 61, NO. 6 NOVEMBER/DECEMBER 2006 President ROBERTO KOBEH GONZÁLEZ FEATURES 1st Vice-President I. M. LYSENKO 6 Initiative promotes a global approach to SMS implementation 2nd Vice-President With an emphasis on achieving worldwide implementation, ICAO’s initial efforts Dr. A. SIPOS to foster safety management have focused on the development of new regulatory provisions, guidance material and a special training programme … 3rd Vice-President J. E. ORTIZ CUENCA 9 Concept of safety management system embraced by many countries Secretary In the United States, a newly issued SMS standard for use by air operators Dr. TAÏEB CHÉRIF is the product of extensive research and collaboration involving industry, Secretary General labour and government safety regulators …

Argentina – D. O. Valente 14 Business model focused on risk management enhances decision-making Australia – S. Clegg Transport Canada’s adoption of a business model for managing its safety programme evolved out of recognition that aviation safety is best served by Austria – S. Gehrer analysing and controlling the risks … Brazil – P. Bittencourt de Almeida Cameroon – T. Tekou 18 Airport operator espouses practical approach to safety management Canada – L. A. Dupuis One strategy for ensuring success is to implement a basic safety management Chile – G. Miranda Aguirre system in stages and gradually win over the trust of operating personnel and China – T. Ma management … Colombia – J. E. Ortiz Cuenca 22 Implementation of ATM safety management systems remains priority for Europe Egypt – S. Elazab Central to Europe’s efforts to improve ATM safety is the widespread promotion Ethiopia – T. Mekonnen of the principles of safety management … Finland – L. Lövkvist France – J.-C. Chouvet 26 Guidance material addresses concerns about protection of safety data Germany – Dr. K. Kammann-Klippstein Legal guidelines developed recently by ICAO focus on enactment of national Ghana – K. Kwakwa laws and regulations that safeguard data collected for safety purposes while also allowing for justice to take its course … Honduras – A. Suazo Morazán Hungary – Dr. A. Sipos 29 Information gleaned from recent accidents provides basis for improvements India – Dr. N. Zaidi Final reports issued by investigation authorities, plus a safety alert arising Italy – S. Monti from the August crash of a regional jet transport, serve the aviation community Japan – H. Kono by underscoring various safety issues … Lebanon – H. Chaouk Mexico – UPDATE Mozambique – D. de Deus 31 ICAO addresses security concern raised by failed terrorist plot Nigeria – Dr. O. B. Aliu • SMS implementation leads to safety enhancement despite strong industry growth Pakistan – M. Rauhullah • Pandemic influenza guidelines now available at website Peru – J. Muñoz-Deacon • ICAO and the Republic of Korea announce training programme Republic of Korea – G. Shin • Symposium puts spotlight on ATM safety • Experts to discuss performance framework for air nav system Russian Federation – I. M. Lysenko Saint Lucia – H. A. Wilson COVER (Photo by R. Ian Lloyd/Masterfile) Saudi Arabia – S. A. R. Hashem Several of the feature articles in this issue are dedicated to the topic of safety Singapore – K. P. Bong management systems, a tool that provides performance-based approaches to South Africa – M. D. T. Peege the management of safety. Under ICAO provisions that took effect in November Spain – L. Adrover 2006, airport operators, aerodrome operators, ATS providers and maintenance Tunisia – M. Chérif organizations worldwide are required to implement such systems. United Kingdom – M. Rossell United States – D. T. Bliss WWW.ICAO.INT 38701.P4 12/7/06 9:36 PM Page 4

Promoting the Development of International Civil Aviation ICAO Journal The International Civil Aviation Organization, created in 1944 to promote the safe and orderly development of civil Editor: Eric MacBurnie Production Clerk: Arlene Barnes aviation worldwide, is a specialized agency of Editorial Assistant: Regina Zorman Design Consultant: François-B. Tremblay the United Nations. Headquartered in Montreal, ICAO develops international air transport standards THE OBJECTIVES of the Journal are to provide a concise account of the and regulations and serves as the medium for cooperation activities of the International Civil Aviation Organization and to feature in all fields of civil aviation among its 189 Contracting States. additional information of interest to ICAO Contracting States and the inter- national aeronautical world. Copyright ©2006 International Civil Aviation ICAO CONTRACTING STATES Organization. Unsigned and Secretariat material may be reproduced in full Afghanistan Denmark Lithuania Senegal or in part provided that it is attributed to ICAO; for rights to reproduce Albania Djibouti Luxembourg Serbia other signed articles, please write to the editor. Algeria Dominican Republic Madagascar Seychelles Andorra Ecuador Malawi Sierra Leone OPINIONS EXPRESSED in signed articles or in advertisements appearing in Angola Egypt Malaysia Singapore the ICAO Journal represent the author’s or advertiser’s opinion and do not Antigua and Barbuda El Salvador Maldives Slovakia necessarily reflect the views of ICAO. The mention of specific companies or Argentina Equatorial Guinea Mali Slovenia products in articles or advertisements does not imply that they are endorsed Armenia Eritrea Malta Solomon Islands or recommended by ICAO in preference to others of a similar nature which Australia Estonia Marshall Islands Somalia are not mentioned or advertised. Austria Ethiopia Mauritania South Africa Azerbaijan Fiji Mauritius Spain Published in Montreal, Canada. Second class mail registration No. 1610. ISSN Bahamas Finland Mexico Sri Lanka 1014-8876. Date of publication of Issue 6/2006: 13 December 2006. Published Bahrain France Micronesia Sudan six times annually in English, French and Spanish. Bangladesh Gabon (Federated States of) Suriname Barbados Gambia Monaco Swaziland SUBSCRIPTIONS: $40 per year (Order No. 3101-A). Single copies available Belarus Georgia Mongolia Sweden for $10 (Order No. 310019). Prices in U.S. funds. For subscription and Belgium Germany Morocco Switzerland circulation inquiries, please contact ICAO Document Sales Unit. Belize Ghana Mozambique Syrian Arab Republic Benin Greece Myanmar Tajikistan Telephone: +1 (514) 954-8022; Facsimile: +1 (514) 954-6769; E-mail: Bhutan Grenada Namibia Thailand [email protected]. Important Note: The current issue may be viewed in PDF Bolivia Guatemala Nauru The former Yugoslav format without delay at ICAO’s website (http://icao.int/icao/en/jr/jr.cfm). Bosnia and Guinea Nepal Republic of Issues dated 2005 or earlier are viewable using the downloadable DjVu Herzegovina Guinea-Bissau Netherlands Macedonia reader. Planned publication dates for 2007 are 16 February, 23 April, Botswana Guyana New Zealand Timor-Leste 15 June, 13 August, 14 September and 20 December. Brazil Haiti Nicaragua Togo Brunei Darussalam Honduras Niger Tonga ADVERTISING REPRESENTATIVE: Yves Allard, FCM Communications Inc., 835 Bulgaria Hungary Nigeria Trinidad and Tobago Montarville St., Longueuil, Quebec, Canada J4H 2M5. Telephone: +1 (450) 677-3535; Burkina Faso Iceland Norway Tunisia Facsimile: +1 (450) 677-4445; e-mail: fcmcommunications@ videotron.ca. Burundi India Oman Turkey Cambodia Indonesia Pakistan Turkmenistan EDITORIAL OFFICE: International Civil Aviation Organization, 999 Univer- Cameroon Iran (Islamic Palau Uganda sity St., Room 1205, Montreal, Quebec, Canada H3C 5H7. Telephone: Canada Republic of) Panama Ukraine +1 (514) 954-8222; Facsimile: +1 (514) 954-6376; e-mail: [email protected]. Cape Verde Iraq Papua New Guinea United Arab Emirates Central African Ireland Paraguay United Kingdom GRAPHIC ART/DESIGN: Bang Marketing (www.bang-marketing.com). Republic Israel Peru United Republic Chad Italy Philippines of Tanzania PRINTING: Transcontinental-O’Keefe Montreal (www.transcontinental- Chile Jamaica Poland United States printing.com). China Japan Portugal Uruguay Colombia Jordan Qatar Uzbekistan ICAO HEADQUARTERS: 999 University St., Montreal, Quebec, Canada H3C 5H7. Comoros Kazakhstan Republic of Korea Vanuatu Telephone +1 (514) 954-8219; Facsimile +1 (514) 954-6077; e-mail: [email protected]. Congo Kenya Republic of Moldova Venezuela Cook Islands Kiribati Romania Viet Nam www.icao.int VISIT ICAO’s website for a wealth of information including Costa Rica Kuwait Russian Federation Yemen past issues of the ICAO Journal, information on advertising in ICAO’s maga- Côte d’Ivoire Kyrgyzstan Rwanda Zambia zine, the latest news releases, a complete listing of ICAO publications and Croatia Lao People’s Saint Kitts and Nevis Zimbabwe audio visual training aids, the ICAO aviation training directory, Secretariat job Cuba Democratic Republic Saint Lucia vacancies, technical cooperation project postings, and much more. Cyprus Latvia Saint Vincent and Czech Republic Lebanon the Grenadines ICAO PUBLICATIONS: The Catalogue of ICAO Publications and Audio-Visual Democratic People’s Lesotho Samoa Training Aids contains a list of all document titles as well as abstracts and Republic of Korea Liberia San Marino indicates the availability of language versions. The catalogue is issued annu- Democratic Republic Libyan Arab Sao Tome and Principe ally in hard copy. Monthly supplements list new publications and audio- of the Congo Jamahiriya Saudi Arabia visual training aids as they become available, as well as amendments and supplements. Most ICAO publications are issued in English, French, ICAO Headquarters Eastern and Southern North American, Central American Russian and Spanish; Arabic and Chinese are being introduced on a gradual African Office and Caribbean Office basis. (The most efficient way to order an ICAO publication is online at 999 University Street Nairobi, Kenya Mexico City, Mexico http://www.icao.int using VISA or Mastercard. All transactions conducted on Montreal, Quebec Telephone: + 254-20-7622-395 Telephone: + 52-55-52-50-32-11 Canada H3C 5H7 Facsimile: + 254-20-7623-028 Facsimile: + 52-55-52-03-27-57 this server are encrypted and secure.) 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Asia and Pacific Office Middle East Office Western and Central DGCA DIRECTORY: ICAO has developed an electronic database of information Bangkok, Thailand Cairo, Egypt on national civil aviation administrations from around the world. The Directory Telephone: + 662-537-8189 Telephone: + 202-267-4841 African Office Facsimile: + 662-537-8199 Facsimile: + 202-267-4843 Dakar, Senegal of National Civil Aviation Administrations (Document 7604) is continuously E-mail: E-mail: [email protected] Telephone: + 221-839-93-93 updated, based on information received from ICAO’s 189 Contracting States. [email protected] Website: www.icao.int/mid Facsimile: + 221-823-69-26 The online directory is available through ICAO’s website at an annual subscrip- E-mail: [email protected] tion fee of U.S. $150. For further information, please contact the Database Administrator ([email protected]).

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ICAO initiative promotes global approach to SMS implementation

With an emphasis on achieving worldwide harmonization, the organization’s initial efforts to foster safety management have focused on the development of new regulatory provisions, guidance material and a special training programme

oversight authorities, operators and serv- the envisaged safety performance has VINCE GALOTTI • ARUN RAO ice providers agree on the level of safety been achieved, after which operators and DANIEL MAURINO that operators and service providers are service providers propose measures for ICAO SECRETARIAT expected to achieve. This safety perform- correcting any deviations. ance may be expressed in complex quan- Senior management accountability is a OMPLIANCE with ICAO stan- titative terms using collision risk model- fundamental component of the perform- dards and recommended prac- ling and associated target levels of safety. ance-based approach, since the frequen- C tices (SARPs) is a cornerstone of However, simpler quantitative approach- cy of prescriptive inspections and reviews international civil aviation safety. es as well as qualitative methods — or by oversight authorities can conceivably However, a rapidly expanding industry even a combination of the two — are decrease. In this sense, operations and and limited resources at oversight increasingly being used as effective safety managers assume a bigger stake in authorities make it increasingly difficult methods for determining and measuring ensuring safety. to efficiently and effectively sustain a pre- safety performance. Performance-based approaches to the scriptive approach to the management of During the second step of the process, management of safety are best exempli- safety based upon regulatory compliance oversight authorities, operators and serv- fied by the safety management system exclusively. This is why it is essential to ice providers decide on the safety (SMS), and the mature concepts that complement the regulatory approach to requirements necessary to achieve form the building blocks of an SMS allow safety management with a performance- agreed targets. These requirements usu- for its implementation on a global basis. based approach. ally include the array of tools and means Indeed, under ICAO provisions that took A performance-based approach to safe- available to operators and service effect in November 2006, aircraft opera- ty management can be presented as a providers. In the third and final step, tors, aerodrome operators, air traffic three-step process. In the initial stage, oversight authorities ascertain whether services providers and maintenance organizations worldwide are required to implement safety management systems.

Management of safety The efficient and effective management of any aviation organization, regardless of the nature of its functions or size, requires the management of basic business processes such as financing, budgeting, communicating, allocating resources, and so forth. In recent years, managing safety has been added to this list. Managing safe- ty should now be as much a part of run- ning an aviation organization as managing any other business process. Moreover, it

k has been well established that effective c e P

. management of safety is good business. K Traditional systems for addressing R a n d safety issues are usually set in motion In companies where management is truly committed to enhancing safety as a core business activity, employees will not be afraid to bring forward their safety concerns only after some triggering event such as

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an accident or incident discloses a safety concern. While such efforts will always serve an important purpose, identifying BUSINESS PLAN UNDERSCORES safety concerns through forensic means, COMMITMENT TO SAFETY MANAGEMENT they need an outcome in order to react and engage the safety management HE ICAO business plan and the the safety component of the organiza- process. In these systems, responsibility organization’s new focus on safety tion’s business plan, a symbiosis that is for monitoring outcomes and reacting to T management might seem as two mutually beneficial. The business plan the safety concerns related to outcomes unrelated efforts born roughly in the same independently measures the effective- may be spread around the organization timeframe. On closer inspection, however, ness of the SMS programme, while the depending on the type of activity involved one realizes that the two initiatives have a implementation of SMS by States allows (e.g. flight operations, maintenance, ramp common conceptual anatomy: both are better input and response to the other and cabin). Furthermore, those account- based on the achievement able for monitoring safety and addressing of measurable results, concerns may not always be clearly identi- both emphasize accounta- fied, and often when they are readily iden- bility, and both feature a tifiable, the individuals held accountable performance review pro- for safety are only at a middle manage- cess that can lead to self- ment level. improvement. This simi- The trend today is towards greater larity is not a coincidence, emphasis on proactive and predictive sys- but was born out of the tems to manage safety. SMS involves the necessity to accept two ongoing routine collection and analysis of emerging realities: the lim- n

safety data during the course of the activi- its on resources, and a o s n e

ties that an organization must pursue every shift from a reactive and g r o day while conducting its core business prescriptive methodology J m i functions, in addition to reacting to the data towards a preventive and J ICAO’s efforts to advance implementation of SMS collected. The SMS may be considered performance-based one. across all aviation disciplines are in step with the process-driven and proactive. It continu- Expeditious implemen- organization’s business-like approach to safety ously collects and analyses sizable volumes tation of safety manage- enhancement of data that provide a principled basis for ment systems is one of the key activities safety strategies supported by the busi- the definition of activities and the allocation arising from ICAO’s safety-oriented busi- ness plan. This input is enhanced of resources to address safety concerns in ness plan. Safety management system through the collection of safety data, a proactive manner. The term “system” (SMS) implementation around the world while response is enhanced through an conveys the notion of an integrated set of is one of the “pillars” that make up the improved safety culture. processes aimed at managing safety that high-level strategy through which the The way forward for both the business crosses intra-departmental boundaries, safety of international civil aviation is to plan and safety management programme thus addressing safety concerns from an be advanced. demands a commitment to safety man- integrated and broad perspective. The overall tactical deployment of agement systems from the highest levels An SMS thus comprises a systemic ICAO’s resources in the sphere of safety of an organization, with transparent approach to the management of safety management is aligned and managed accountability. Just as ICAO’s business that puts in place the necessary organiza- through the business plan with the goal plan evolved from institutional action tional structure, accountability, policies of delivering a consistent and harmo- sparked by its member States, the inter- and procedures. In order to reinforce the nized global approach to the concepts national standards that apply to safety conviction that safety management is a and implementation of SMS and the will require States to implement pro- managerial business process, basic SMS implementation of performance-based grammes that include acceptable levels of requirements should include provisions safety regulations. These anticipated safety as defined by authorities, operators for an organization to establish lines of results are complemented by a defined and air navigation services providers. responsibility for safety throughout the set of measurable indicators through For these two interlinked initiatives to organization, beginning with the senior which the effectiveness and efficiency of survive, patient attention is required from management level. the ICAO initiative will be monitored. all civil aviation stakeholders. Perhaps In addition to the systemic and proac- SMS is thus firmly embedded within continued on page 38 tive nature of managing safety, which is

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relatively concrete and understandable, While many States and organizations The point of all these efforts has been to the evolution to a more managed have been involved in implementing safe- facilitate a harmonized global approach to approach to safety and to the SMS also ty management systems over the years, the implementation of SMS. Harmoniza- requires a change in the way that people ICAO has noticed some discrepancies tion will lead to a better and common think about safety, a collective perception concerning the key terms, concepts and understanding of SMS, extensive sharing that may be referred to as culture. hypotheses they appropriate. This was of information and data, rapid expansion of Although culture cannot be regulated or evident, for example, in the way that safety management systems, common implemented in the way that more con- States attempted to adapt the notion of an course material and readily adaptable crete systems and rules may be, manage- “acceptable level of safety.” Discrepancies model regulations, among other things. Very importantly, one way ICAO has supported SMS implementation has been to amend SARPs to establish harmonized safety management requirements in spe- cific annexes to the Chicago Convention.* The Safety Management Manual, a central source of safety management information, offers essential guidance material con- cerning these harmonized provisions. It includes a section on generic safety man- agement concepts applicable across avia- tion activities, as well as sections on the specific activities of operators, mainte- nance organizations, ATS providers and aerodrome operators. n o s In continuing its initiative, ICAO will n e g r have to complete several critical tasks by o J m

i the autumn of 2007. All Chicago J In recent years safety management has been added to the list of traditional business Convention annexes, for example, will processes that are required to run any aviation organization have to be assessed to determine the fea- ment philosophy can be transmitted in were also apparent in the use of various sibility of developing SARPs compatible clear and unambiguous terms through- terms, as well as in regulatory develop- with a performance-oriented regulatory out an organization. ment and in the manner that SMS was approach to safety management. Model Once convinced that SMS is good busi- being explained and taught. regulations will be required to support ness and that it should become an integral The organization initiated a substantial adoption of a performance-based regula- part of an organization, management effort in 2005 to harmonize these con- tory approach by States. Material will be should take definitive measures to ensure cepts and terms and to combine all of its needed to guide national oversight that its commitment to managing safety as safety management guidance into a sin- authorities in integrating safety manage- a core business activity is recognized by gle comprehensive document entitled the ment practices and to assist aviation the staff. Over a period of time, staff Safety Management Manual (ICAO organizations in applying SMS. Finally, a should feel at ease about bringing forward Document 9859). It also began to coordi- programme of training courses to assist safety-related information. The combina- nate, research and study those ideas that continued on page 38

tion of rules and regulations and concrete were vaguely understood. The result was * The amended annexes are Annex 6, Operation of action — together with an explicit change a clear and common perception of SMS Aircraft (Part I, International Commercial Air Transport — Aeroplanes and Part III, International Operations — in management philosophy — should and its components, and a comprehen- Helicopters); Annex 11, Air Traffic Services; and Annex result in a greatly improved safety culture. sive guidance document for SMS imple- 14, Aerodromes (Volume I, Aerodrome Design and Operations). In all, 18 annexes to the Chicago Convention mentation. The next step involved devel- contain provisions for the safe, secure, orderly and effi- ICAO action oping common material to support train- cient development of international civil aviation. ICAO’s strategic objectives for the peri- ing and ensure that operational and safe- All three authors are employed in the Air Navigation od up to 2010 include the enhancement of ty managers, as well as operating person- Bureau at ICAO headquarters, Montreal, where Vince global civil aviation safety, a goal that calls nel, more fully understand fundamental Galotti is Chief of the Air Traffic Management (ATM) Section; Arun Rao is Chief of the Aerodromes, Air for the organization to support implementa- safety and human factors concepts such Routes and Ground Aids (AGA) Section; and Capt. tion of safety management systems across as “just” culture, the role of latent condi- Daniel Maurino, of the Flight Safety (FLS) Section, is the Coordinator of the Flight Safety and Human all safety-related disciplines in all States. tions, and aspects of human error. Factors Programme.

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Concept of safety management system embraced by many countries

In the United States, a newly issued SMS standard for use by air operators is the product of extensive research and collaboration involving industry, labour and government safety regulators

The FAA, together with ICAO, recog- can be integrated with the other manage- DR. DON ARENDT nizes the need not only for a more sys- ment systems of the airline as well as pro- FEDERAL AVIATION ADMINISTRATION tems-oriented approach to safety than has vide an interface with the regulatory CAPT. WILLIAM YANTISS been previously practised, but for a more oversight system. UNITED AIRLINES managerial approach to safety on the part of both government and industry. The process CAPT. ANA VEGEGA Notwithstanding the FAA’s responsibility At the time that the FAA began consid- AIR LINE PILOTS ASSOCIATION to promulgate regulations and standards, ering development of SMS standards and (UNITED STATES) progress in aviation safety can be implementation by U.S. airlines, several safety management system enhanced with a more integrated and other countries had already developed (SMS) standard for use by aircraft cooperative relationship with industry material on the subject, as had the Air operators of all types and sizes versus a legalistic, adversarial approach. Line Pilots Association (ALPA) and sever- was issued by the Federal Aviation Safety management is, therefore, more al U.S. airlines. A number of other innova- Administration (FAA) in late June 2006. rightly viewed as a shared effort by gov- tive quality management and system safe- The new standard is the product of exten- ernment and industry. ty efforts were also in play that employed sive research as well as inputs from indus- Trends in management theory indicate many of the concepts seen in a typical try, labour, and both U.S. and other govern- that a structured approach to manage- SMS. It was clear at the outset that the ment safety regulators, and is described in ment, where clear goals and requirements future system would benefit from com- an FAA advisory circular entitled are set and where man- monality and harmo- Introduction to Safety Management Systems agement processes are nization with existing Policy: for Air Operators. put in place to assure (Structure) systems, and so the Under an ICAO provision that took attainment of these goals, FAA/industry team effect on 24 November 2006, member are more reliably effec- commenced a process Safety Risk Mgmt. States are required to ensure that aircraft tive than other approach- Assurance of research to avoid operators, aviation maintenance organiza- es. The FAA is in the reinventing the wheel. tions, air traffic services providers and process of instituting a Safety Promotion: Culture/Environment However, the FAA/ aerodromes implement safety manage- completely systems- Figure 1. The relationship of major industry team has also ment systems. The United States, among based approach for air elements of an SMS made its own unique many other nations, has enthusiastically carrier oversight. Both the agency and contribution along the way. endorsed the SMS concept. industry recognize that this transition can- The research project was conducted not be effective through the regulator’s under contract to the FAA Technical Product of necessity actions alone. System safety must be Center after a review of requirements The current operating environment for infused into the management systems of using a focus group with representatives commercial aviation is characterized by air operators and other service providers from different FAA entities, several major complexity and almost constant change. if it is to have the desired effect on safety airlines and ALPA. This requires that air operators and avia- outcomes. The research project entailed a tion service providers constitute open sys- It is to this end that the SMS standard detailed literature search of documented tems, continually adapting to this dynamic was developed. The standard is designed aviation safety management systems, as environment in order to survive. The mod- to be used by operators to develop a man- well as existing management systems ern aviation system is best viewed as a agement framework for safety risk man- developed for quality assurance, occupa- “system of systems” with complex interde- agement and safety assurance. Moreover, tional safety and health, and environmen- pendencies and a variety of business mod- the standard postures the safety manage- tal protection. Beyond the literature els and adaptable relationships. ment efforts in such a manner that they search, site visits and interviews were

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conducted with representatives of regula- latitude to build programmes that align processes defined in ISO 9000. tory agencies and operators in Australia, with their existing or proposed business Therefore, ISO 9000 was used as the Canada, New Zealand, and the United and management models while assuring basic template in these areas. Kingdom. Interviews were also conduct- a common set of SMS processes across Figure 2 provides a functional descrip- ed with representatives of the Joint operators. tion of the SMS standard’s clauses, show- Aviation Authorities (JAA) and several The individual processes in the stan- ing the organization of the document and third-party industry groups. dard’s clauses were organized under the the relationships of its principal elements. The research team also considered the structure of the “four pillars” defined in Clauses four through seven constitute work of several contemporary aviation the draft SMS manual for the U.S. Air the four pillars of the SMS as described theorists, notably, Dr. James Reason, and Traffic Organization (ATO), which was above. Clause 4 (policy) contains a several other common sources of system already under development because of an requirement for procedures and organi- safety background, such as the U.S. mili- earlier ICAO mandate for implementation zational controls to be defined through- tary standard Mil-Std 882. of safety management systems in the air out the system. A number of individual Standard development. As the project traffic management (ATM) field. The processes also call for measurable crite- progressed, a growing recognition of the four pillars constitute policy, safety risk ria. The remainder of the figure shows need for a universal standard emerged. management, safety assurance, and safe- subprocesses that are described within The FAA/industry team perceived that ty promotion. Of these cornerstones, the each major clause. there was a need for conceptual harmo- risk management and safety assurance Safety policy is the underpinning of the nization across the various service pillars define the two principal, interac- SMS. Effective safety management providers in the aviation system. A team tive processes of the SMS. The policy pil- begins with policies that convey to all was formed under the FAA’s Joint lar provides structural documentation of staff members the top management’s Planning and Development Office the system, including a requirement for emphasis on safety and their objectives. (JPDO) to develop a universal SMS stan- assignment of responsibility and authori- These policies include assignment of dard template that was designed for ty for management processes and provi- responsibility and authority throughout broad applicability across all types of avi- sion of related procedures. The proce- the organization with respect to all safety- ation service providers. This approach dure for safety promotion, along with cer- related functions. Policies must also be tain policy require- translated into procedures to provide ments, provides for an staff with clear instructions for accom-

Policy organizational environ- plishing their safety-related functions as Cl. 4 Safety Risk Safety Safety ment that supports a well as organizational controls to ensure Management Assurance Promotion healthy safety culture. that these functions are performed as (SRM) Cl. 5 (SA) Cl. 6 (SP) Cl. 7 Procedures Figure 1 shows the intended. System Data Audits Comm Descrip relationship of these Safety management is founded on risk Process Invest. Hazard elements in the SMS. management. The fundamental objective Controls Analysis Reports Training Ident Systems must also of any safety programme is to identify Risk Assmt facilitate audits by both hazards, analyse and assess associated Analysis operators and third risks, and design and implement controls Risk P/C Assmt Action parties. For this rea- for those hazards and risk factors. The

Risk son, the general format safety risk management (SRM) pillar in Control of the ISO standards the FAA’s SMS standard for air operators was favoured as a pat- is based upon a model that is used in sev- Figure 2. Functional description of the FAA SMS standard tern. The environmen- eral popular system safety training cours- allowed for discussion among representa- tal standard, ISO 14001, was chosen as es, including the course taught at the tives of the component industries of the the basic template. This standard was FAA Academy. The FAA’s SMS standard system and their respective oversight selected because the system require- starts with a careful analysis of the orga- organizations, and provided a forum for ments for environmental protection, like nization’s systems and goes on to provide review of the emerging documents. those required for safety, are based more structured processes that result in the Structure and functions. The standard on objective assessments of the impact development of risk controls. The princi- is designed to take a functional orienta- on system users and on the public than pal steps in the SRM process include sys- tion; that is, requirements are laid out to on customer satisfaction. At the same tem and task analysis, identification of delineate what processes are expected time, the safety assurance processes of hazards, and risk analysis, assessment rather than how they will be implement- the SMS drew heavily on the auditing, and control. Each of these steps is ed. This allows operators the maximum analysis and preventive/corrective action described in brief below.

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• System/task analysis: Both physical ment systems that must be in place for ing blame and punishment. The safety pro- (e.g. equipment, aircraft, facilities) and the business enterprise to run. Moreover, motion pillar is also closely integrated with organizational systems are to be defined other areas of health and safety must be the SRM and SA pillars, as it is an important in order to gain a thorough understand- managed by these businesses, such as source of information for both. ing of the conditions in which hazards occupational safety and health manage- The foundation of a healthy safety cul- may arise. ment systems and environmental man- ture is based on well-designed operational • Hazard identification: Systems, process- agement systems. While the focus of the procedures that are harmonized cross- es and tasks are analysed to identify the SMS is on safety, the standard was draft- functionally and then fully engrained into existence or conditions that employee behaviours using could create hazards to per- a robust employee train- sonnel or property. ing programme. This is • Risk analysis: Hazards clearly a responsibility of are further analysed to the management team. determine factors related However, the conduct of to risk severity and likeli- operational activities in a hood. These will later safe manner rests on the become the basis of risk shoulders of each employ- controls. ee as they perform techni- • Risk assessment: Overall cal and service-related risk is evaluated for its tasks. Safety is, therefore, acceptability. The FAA’s both an individual and n o s

SMS advisory circular, AC n corporate responsibility. e g r

120-92, uses a risk matrix o Safety promotion is laced J m based upon severity and i throughout all initial and J likelihood definitions pro- The final version of the FAA’s SMS standard and associated guidance recurrent training acti- vided in the ICAO Safety material will be based on feedback and data analysis involving a vities and also throughout diverse group of operators and service providers Management Manual. all operations so that it can • Risk control: Where necessary, con- ed in full recognition of the need for air- continue to nurture the organization’s trols are developed to eliminate hazards lines to balance requirements and to safety culture. or to reduce their potential effects. These make them fit together with a minimum controls then become system require- of duplicated effort. Programme integration ments, which will be continuously evalu- Safety promotion, the final pillar, is the The SMS standard was developed with ated by the safety assurance function of foundation of a sound safety culture. It the understanding that various safety pro- the SMS, a process that operates similar was developed with recognition of the gramme components might already exist to a quality management system. importance of a sound safety culture to separately in an organization. The SMS Safety assurance, the third cornerstone the safety management process. concept provides a framework for inte- of the safety management system, Employee knowledge, involvement and grating all of these government and involves safety, quality and integrated motivation are crucial to safety manage- industry programmes into a comprehen- management. Risk controls developed ment success. sive system. Most of the existing pro- under the safety risk management pillar The safety promotion pillar stresses grammes are treated as optional, but cur- now become organizational system training and awareness, communication, rent and future efforts will be directed requirements. Safety assurance involves and active participation. It also sets the toward more seamless integration. taking these requirements and applying groundwork for support of a “just cul- Several programmes have more exten- quality management techniques to the ture” in which employees are encouraged sive requirements that are over and process of ensuring that these controls to report safety deficiencies with confi- above the minimum requirements of the are being correctly implemented and that dence that their management will be fair SMS standard. For example, the standard they are producing the desired results. and responsive to their input, and without requires participating operators to have a The group that developed the standard fear of punitive actions. confidential employee reporting system kept in mind that airlines are really a col- A sound, just safety culture recognizes and to use these reports in the safety lection of systems. There are the techni- that well trained, motivated and responsible assurance process. The Aviation Safety cal systems that make up flight opera- employees are nonetheless vulnerable to Action Programme (ASAP), for example, tions, ground operations, maintenance making errors and emphasizes correction provides such a process with detailed and training, as well as other manage- of safety deficiencies rather than apportion- data collection, review, analysis and data

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SMS STANDARDS

management functions. ASAP was and system effectiveness is again meas- fact, the most important functions of the designed for large- to medium-sized oper- ured by these component programmes, SMS are carried out by line management, ators and the requirements may be thus continuing the cycle. Senior man- those who are responsible for production beyond the resources of many smaller agement is able to track the organiza- and who have the authority to direct activ- organizations. Thus, the SMS standard tion’s health when the information gener- ity and allocate resources. was created with fundamental require- ated by these programmes is effectively ments while treating the more extensive- integrated and analysed. The future ly developed programmes such as ASAP Safety management systems are cur- as an optional means of meeting the Oversight system rently voluntary in the United States, and requirements for those organizations The FAA fully supports the ICAO posi- AC 120-92, the current SMS document, capable of making the necessary invest- tion that safety should be addressed by a describes an optional process for air opera- ments. ASAP is one non-punitive report- managerial approach, and furthermore tors. However, the FAA came out in favour ing system, but other systems can also be that there are distinct roles for both gov- of the recent amendment to ICAO Annex designed to meet the requirements of the ernment regulators and the business 6, including a new requirement for States standard. entities that they oversee. The FAA to ensure that aircraft operators implement The standard is written so that a com- began a movement to a more systems-ori- safety management systems, and it intends pany can develop an integrated manage- ented method of oversight in 1998 with to implement the Annex 6 provisions ment system to tie safety and quality dis- the advent of the Air Transportation according to the prescribed schedule. ciplines together by harmonizing sup- Oversight System (ATOS). Since then, To this end, the FAA is in the process porting programmes with the organiza- the agency has encouraged operators to of organizing a proof-of-concept with tion’s risk management efforts. Since use the same tools that are used by FAA feedback and data analysis across a inspectors to design and evaluate diverse set of sizes and types of operators PROTECTION PRODUCTION organizational systems. Safety is and other service providers. In this man- most effectively achieved though an ner, both industry and government par- OBJECTIVE: PUBLIC SAFETY Direct sampling open and collaborative approach, ticipants can learn important lessons (e.g. surveillance) FAA’s Safety wherein information moves freely not while the systems are still voluntary and Management (Oversight) System OBJECTIVE: SERVE only inside the oversight system and can consequently be tailored more freely. CUSTOMER REQUIREMENTS the airline, but between them as well. A collaborative approach among the Figure 3 depicts the general rela- FAA and industry groups, including rep- Process OBJECTIVE: tionship between the three main enti- resentatives of management, labour CONTROL ties in the safety equation. The first organizations such as ALPA and other SAFETY RISK Inputs Outputs = Products/services Operator’s Safety distinction made in the model is that industry advocacy groups, will be used Management System between production and protection, a over time, and analysis of the proof-of- concept brought forward by Dr. concept experiences will allow for better Figure 3. Relationships between an operator’s James Reason, a prominent organiza- implementation of the SMS concept SMS and the oversight system tional theorist. In traditional over- across the industry. The final version of each of these programmes can identify sight, most of the interaction between the the standard and associated guidance and assess risk from a unique perspec- oversight system and the business entity material will be drafted and edited based tive, integration of management systems occurs along the diagonal line, direct, on experience. can be highly beneficial. The role of an interventionist approach. In the safety continued on page 39 internal evaluation programme (IEP), for management approach, safety assurance Dr. Don Arendt is Manager, FAA Flight Standards Safety example, is to assure the safety of opera- by the regulator is primarily carried out Analysis Information Center. Capt. William Yantiss is tional activities, verify regulatory compli- via the relationship with the operator’s (Acting) Vice President for Safety, Security and Quality Assurance for United Airlines, and Capt. Ana Vegega is an ance, ensure conformance to organiza- SMS. Safety risk management, which is Airbus A320 captain for United Airlines and Director of the SMS Project for the Air Line Pilots Association. Others who tional procedures, and identify opportuni- primarily the responsibility of the opera- contributed to this article include Scott VanBuren and Carl ties for improvement. An IEP will be tor’s management, is carried out in the Marquis, of the FAA Air Traffic Oversight Service, the lead- ers of the SMS standard development team; Linda Sollars, more effective if it evaluates safety issues SMS. However, the continuous and open Director of System Safety for JetBlue Airways, who chaired identified by programmes such as ASAP relationship facilitates close collaboration the FAA/industry focus group that oversaw the initial SMS research project; Dr. Douglas Farrow, who represented the and Flight Operations Quality Assurance on both risk management and safety FAA Flight Standards Voluntary Programs Branch; and (FOQA) or other sources of safety infor- assurance. Michael Lenz, FAA Commercial and General Aviation Division, who represented general aviation interests and mation that may also be in place in the The depiction of protective and produc- oversaw production of the FAA’s SMS advisory circular. company. Corrective actions are imple- tive functions does not, however, imply a Opinions expressed in this article are those of the authors and are not necessarily the official position of the FAA or mented for these safety/quality issues matching organizational structure. In other organizations with which the authors are affiliated.

12 ICAO JOURNAL 38701.P13 12/7/06 9:37 PM Page 13

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SMS IMPLEMENTATION

Business model focused on risk management enhances safety programme decision-making

Regulator’s adoption of a business model for managing its safety programme evolved out of the recognition that aviation safety is best served by analysing and controlling the risks

Canadian aviation legislation or depart- develop and administer policies and regu- BRYCE FISHER mental policy documents. lations for the safest civil aviation system TRANSPORT CANADA The dictionary is equally unhelpful in for Canada and Canadians, using a sys- this regard. The Concise Oxford tems approach to managing risks.” DOPTION of a business model, Dictionary defines safety as: “freedom That safety is the condition where risks as Transport Canada has discov- from danger or risk; being sure or likely are managed to acceptable levels is not A ered, is an effective way to deliv- to bring no danger; being safe.” The dic- new. It has been implied in the aviation er and manage a civil aviation pro- tionary describes an absolute condition industry for many years. However, the gramme, in part because it applies equal- while few, if any, situations are complete- wider, explicit use of this definition is a rel- ly to safety as to other broader manage- ly free from danger or risk. Like all atively recent phenomenon. Defining safe- ment issues. human enterprises, aviation is fraught ty in context and expressing the mission in The business model introduced recent- with risk. terms of risk helps clarify the regulator’s ly by Transport Canada Civil Aviation The absence of an operational defini- role and limitations. This new mission (TCCA), which is based on the manage- tion of safety has been problematic for statement provides clarity of purpose: not ment of risks, will help the organization civil aviation. It is susceptible to wide, only does it spell out TCCA’s goal, but it make better decisions in an environment subjective interpretation, which can lead also states how and for whom the organi- that is forever beleaguered by competing to conflicting priorities and the conse- zation is delivering its programme. demands for limited resources. quent allocation of resources to lesser The business model. All parties involved While regulatory authorities may find issues; it hinders consistency in the deliv- in delivering on the mission must be able the business model approach worthy of ery of regulatory programmes and quan- to see the whole, understand how things closer examination, aviation companies titative performance measurement. should work, and, more importantly, how may as well, because risk management is Simply put, in the absence of a formal, they contribute to value creation. The an integral part of a safety management operational definition of safety, the dictio- business model was developed to articu- system (SMS). The tactics and strategies nary’s version cannot apply in an aviation late and illustrate how this works. used to mitigate risk may be different, context, or any other low-probability, Some may argue that, as a government but the processes used to arrive at such high-consequence industry for that mat- entity, TCCA does not need a business tactics and strategies are the same. ter. Perhaps it was in a similar light that model; it is not a business, as it is not Although the focus of this article is on William W. Lowrance defined safety as “a involved in value creation. But the public aviation safety, the business model has judgement of the acceptability of risk, and values safety. Both the public and con- broad applicability: it can apply to securi- risk, in turn, as a measure of the probabil- sumers of aviation services in particular ty or environmental topics, and can also ity and severity of harm to human look to TCCA to act as their safety advo- apply to other modes of transport or man- health.”* He summarizes by stating that cate, ready to intervene in the sector as agement issues. “a thing is safe if its risks are judged to be necessary to ensure appropriate meas- TCCA’s adoption of the business model acceptable.” ures are taken to manage aviation risks. that is described below evolved out of For the reasons stated above, in Flight This is value creation, and TCCA’s new recognition that safety is not an absolute 2010 — TCCA’s current strategic plan — mission statement is its value proposition. condition, but rather one where risks are a working definition of safety is provided A business model incorporates all criti- managed to acceptable levels. as “the condition where risks are man- cal activities needed to deliver the value aged to acceptable levels.” proposition. To deliver on its new mission Safety defined The new mission. Having defined safety and focus its interventions where they can Although Transport Canada has long in terms of risk, TCCA refined its mission have the most impact despite increasingly emphasized the paramount importance of statement, which aligns with the larger limited resources, TCCA has adopted a safety, the word “safety” is not defined in departmental mission, as follows: “To business model that governs all activities

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SMS IMPLEMENTATION

INITIATION PRELIMINARY RISK ESTIMATION RISK CONTROL MEASURE IMPACT ANALYSIS RISK EVALUATION AND INTERVENTION AND COMMUNICATE

Diagnosis YES NO

NO Proactive Filter and analysis Data of micro and macro data to identify and Transfer understand issues Understand Have risks Immediate NO YES Do we need to YES Terminate/Eliminate the hazards been mitigated major concern? intervene? and results Continuous and risks? Treat/Mitigate communicated? monitoring of the risk Reactive system and NO: Tolerate/Accept Data specific issues the Risk YES

Report Report

New data may be captured when implementing a mitigation strategy

Figure 1. Business model used by TCAA as a means of managing safety through risk management

and processes in the delivery and manage- to derive meaningful information from tolerable or acceptable?” If the answer is ment of its oversight programme. which decisions about risk can be made. affirmative, the risks are considered As shown in Figure 1, TCCA’s business Ideally, risk analysis should address all acceptable and no intervention is required. model incorporates five phases: initiation, dimensions that could lead to an individ- However, the organization enhances moni- preliminary analysis, risk estimation and ual, organizational or systemic accident. toring and contributes to continuous learn- risk evaluation, risk control and interven- These accident dimensions can be broad- ing by producing a report and storing this tion, and impact measurement and com- ly categorized as active failures and latent in a safety intelligence repository for munication. conditions. Regulators must take the future use. If the answer is negative, the Initiation and preliminary analysis. broadest view and assume that latent con- risks are deemed not acceptable, and the Except for those circumstances requiring ditions affecting individual behaviour, follow-on question becomes: “How do we the immediate tactical intervention on workplace conditions and organizational intervene to bring the hazardous condi- the part of the regulator to stop a situa- factors transcend the boundaries of a par- tions into the range of acceptability?” In tion that poses an immediate threat to avi- ticular aviation company and encompass exploring possible solutions, the dimen- ation safety or respond to an accident or the legislative, socio-economic and politi- sion of cost-benefit is examined in the con- significant incident, the application of the cal dimensions. Culture must also be con- text of risk mitigation. The purpose is to business model requires, first and fore- sidered in the analysis since professional, establish whether the benefits of any pro- most, the acquisition of safety intelli- organizational, industry and national cul- posed risk mitigation strategy offset the gence before making any decisions. tures may influence the decisions, behav- costs of its implementation. Safety intelligence is simply the data iours and actions of the players involved. Risk control and intervention. Gener- that are analysed to produce information The SMS approach is being imple- ally, there are three strategies for man- necessary to understand the risk. When mented to encourage the proactive man- aging risk: eliminate the hazardous con- visualized as a pyramid, safety intelligence agement of conditions that could lead to dition, mitigate the risks, or transfer the incorporates data at the bottom layer of accidents. These dimensions can be risk by, for example, requiring carriage the pyramid, from which information, applied to normal working situations, haz- of liability insurance. In terms of mitiga- knowledge and wisdom are derived in ards, incidents or accidents. By analysing tion, regulators can design and execute hierarchical fashion. Through an analyti- data from each dimension, the output is intervention strategies that address one cal process, these data are transformed safety intelligence regarding the actual or or more components of the risk equa- into information; the synthesis of this emerging hazard expressed in terms of tion, in particular the probability, severi- information leads to knowledge, and over risk, specifically its probability, severity ty or amount of exposure associated with time this body of knowledge becomes the and the degree of exposure. the risk. accepted wisdom. Risk estimation and risk evaluation. Typically, aviation authorities can avail Data collection includes both reactive Once the hazard — both the likelihood of themselves of legislative or policy means data obtained from occurrences, plus its manifestation and its severity — is to develop a strategy that can be used to proactive data that may originate from understood, the question is then asked: varying degrees to mitigate the risks. hazard reports. These data are analysed “Are the risks associated with the hazard The accompanying table (Figure 2) sum-

NUMBER 6, 2006 15

38701.P16 12/11/06 6:55 PM Page 16

SMS IMPLEMENTATION

marizes some of the more frequent tac- ments to the original plan need to be as the Incursion Prevention Action Team, tics employed in the legislative or policy made. It is also important to justify cur- made up of a cross-section of aviation spe- areas. Such tactics can be effective rent or future resource expenditures. cialists, was created to manage the risk whether used in whole or in part. If the risks are managed to acceptable mitigation project. In designing an intervention, care levels, a report is prepared and stored in After several years, the risk mitigation should be taken to ensure that the the safety intelligence repository. The strategy has proven successful: the num- approach adopted holds promise of miti- project team may then be disbanded, but ber of runway incursions has stabilized, gating the risks to within acceptable lev- the issue at hand must continue to be and more importantly, the severity of run- monitored. The lessons learn- way incursions has decreased. (For more Legislative Policy ed in the execution of the risk on this safety initiative, see “Study on Rule-making Promotion and Education mitigation strategy can pro- runway incursions identifies contributing The making, amending, or repealing of: • Conferences, symposia, colloquiums • Laws • Newsletters, journals, papers vide further intelligence and factors and recommends solutions,” • Regulations • Briefings • Standards • Multi-media safety products help identify the triggers that Issue 1/2002, pg. 13; and “Problem of The issuance/withdrawal of orders, enhance monitoring capability. runway incursions among most urgent exemptions, decrees or other items If the risk mitigation strate- issues facing aviation community,” Issue Regulatory Oversight Strategic Investments/Divestiture gy failed in achieving the 3/2002, pp. 26-27.) • Educating for compliance • Privatize desired results, this leads to a Challenges and benefits. The opera- • Monitoring • Commercialize • Inspection • Nationalize diagnostic exercise to discov- tional definition of safety and the busi- • Audits • Subsidize er where in the application of ness model it calls for do raise several • Enforcement the business model the fail- broad questions. What are the risks Authorizations (certification) Strategic Leverage ure occurred. The answer inherent in aviation? Who is at risk? And, The issuance, or withholding the issuance, • Public/Private Partnerships of certificates, licences, permits, or other • Industry empowerment may lie in the design or exe- if the risks are to be managed to accept- authorizing documents cution of the mitigation strate- able levels, what level of risk is accept- Figure 2. Regular risk mitigation strategies fall under gy, the decision-making pro- able to those at risk? legislative or policy areas cess (i.e. the misapplication Answering questions such as these is els, meaning that the outputs, intermedi- or inappropriateness of risk criteria), or not easy, but Transport Canada is pre- ate and ultimate outcomes must be the analysis or data-capturing phases. pared to meet this challenge. Out of observable and measurable. In addition, Regardless of the outcome, an assess- necessity, it will perform the required cal- the strategy must be commensurate to the ment of what worked, how well it worked, culations to arrive at a benchmark level of level of risk in terms of its cost-benefit. and what did not work, should be carried risk or risk profile from which it can The execution of the risk mitigation out — if for no other reason than to learn establish goals, design and execute strategy should be managed as a project from each experience and improve the appropriate mitigation strategies, and with a team and a project plan that processes of the business model itself. measure and report on the results. includes project accountability, timelines, The rigorous application of the busi- resources and performance measures. Case study: runway incursions ness model will enable TCCA to target its Aviation companies have a myriad of In 1997, Transport Canada and Nav interventions where they can have the strategies at their disposal to mitigate Canada, the country’s private air navi- most impact for the safety of consumers risk as well. These include engineered gation services provider, noticed a of aviation services. It will enable better systems; organizational, procedural, and significant increase in the number of and more empirical performance meas- behavioural fixes, such as training and runway incursions. Runway incursion urement, allowing air travellers to con- education; and/or personal protection data was collected, validated and nect TCCA’s actions with visible out- from hazards. Safety literature would, analysed. The result of this analysis was comes. In this way, Transport Canada will however, encourage aviation companies a better understanding of the active be able to achieve its twin objectives of to not rely solely on one strategy, but failures and latent conditions behind improving aviation safety while enhanc- rather, as espoused by James Reason, a runway incursions. ing confidence in its oversight pro- combination of strategies that achieve The level of risk posed by runway gramme. I defences in depth. incursions was deemed unacceptable. To

Measure impact and communicate. mitigate the risk, a number of both short- * Of Acceptable Risk, by William W. Lowrance (1976) After a time, the results of the risk mitiga- and long-term risk mitigation tactics were tion strategy should be ascertained. This initiated, including regulatory and proce- Bryce Fisher is the Manager of Safety Promotion and Education in the System Safety office at Transport is done to determine whether the dural changes, increased oversight activi- Canada Civil Aviation, Ottawa. This text is an adaptation planned interventions are achieving the ties, and launch of an awareness cam- of an article published in Transport Canada’s Aviation Safety Letter (Issue 2/2006), which is distributed to all desired results and whether any adjust- paign, to name but a few. A team known licensed pilots in Canada.

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SMS IMPLEMENTATION

SAFETY MANAGEMENT SYSTEMS 101

HERE has been much talk in avi- broached between the same covers. Notwithstanding the absence of a uni- ation circles in the past few Some hold the view that an SMS is a versally accepted construct for an SMS, a T years about safety management framework for the prevention or reduc- comparison of some of the “SMS stan- systems as if they were something com- tion of personal injury or death in the dards” that have been around for a while, pletely new. This is far from the case. workplace. Others view it as a system notably in the provision of air traffic serv- The safety management system has a within which risk management operates. ices and the nuclear and environmental long history in the areas of occupational From a financial perspective, account- industries, reveals certain universal prin- safety and health, the chemical manufac- ants and managers believe it is a combi- ciples. What follows is an expose of the turing sector, nuclear power generation nation of tactics that contributes to the principles that formed the basis of and research, the environment and else- bottom line. Human factors experts TCAA’s safety management system brief- where. It is true that broad application of think of it as a system that eliminates, ing campaign, which began in 2001. For the safety management system in avia- reduces or otherwise attempts to control a presentation of these concepts and tion is a relatively recent event, but the the conditions within systems and principles, visit the Transport Canada establishment of safety management sys- organizations that are conducive to website (www.tc.gc.ca/civilaviation/SMS/ tems in the provision of air traffic servic- human error. Breeze/menu.htm). es has been a requirement in Europe, From a regulatory perspective, an SMS The term safety management system Australia and New Zealand for some is a means for incorporating measures to has many definitions. But in a speech at time, and the subject has been the focus ensure compliance with safety legislation. a safety conference in Toronto in of many aviation conferences and semi- Viewed in a legal light, the SMS is an November 2000, Prof. José Blanco nars. approach that attempts to minimize law- explained it simply by breaking the term Armed with the knowledge gained suits. For a marketing executive, however, down to its constituent parts: the term from other sectors’ experience with it comprises strategies that will translate “safety” is used to mean the condition SMS, one would have expected aviation’s into a larger market share. where risks are managed to adaptation of safety management sys- Quality assurance adherents One would have acceptable levels; the term tems to be a relatively effortless affair. see safety management sys- expected aviation’s “management” — to distil it The opposite seems to have been true, as tems as a continuous im- to its purest form — can be adaptation of different aviation disciplines or jurisdic- provement loop-type process defined as the allocation of tions have adopted inconsistent that aims to reduce failures. SMS to be a resources; and the term approaches. While some have opted for There are, in a word, endless relatively “system” refers to an engineering models, others have chosen viewpoints to consider. organized set of things that human factors models, or hybrids, and Some experts would argue effortless affair interact to form a whole still others have embraced ISO standards that these different percep- (typically interrelated pro- based on the tenet that quality and safety tions of safety management systems cesses supported by policies, proce- are two sides of the same coin. Some work at cross-purposes or are otherwise dures and tools) which is required for companies have achieved positive incompatible, or that safety performance the delivery of goods or services. results, others have not. can only be enhanced at the expense of Turning this upside down, we could This may not be an indication of any other efforts, as if it were a binary func- say that a safety management system is failing, but rather evidence of the lack of tion. Meanwhile, regulators and stan- an organized set of interrelated process- an underlying and universally accepted dards-making bodies must search for an es to allocate resources to achieve the construct for safety management sys- approach to safety management that condition where risks are managed to tems. As a subject, safety management would be relatively easy to institute and acceptable levels. systems have received their fair share of enforce. A safety management system can treatment by various experts. These trea- It may be that a safety management incorporate three strategies focused tises, however, have tended to examine system is all of these things or has the respectively on safety, management, and the concept through a coloured lens, be it potential, at a minimum, to embody all business. Safety strategies concern them- a safety, business, legal or other perspec- these viewpoints. In other words, diverse selves with the achievement of two major tive. Rarely have these and other aspects perspectives can contribute to a fully goals: they concern compliance with both of safety management systems been functioning SMS. continued on page 36

NUMBER 6, 2006 17 38701.P18 12/7/06 9:37 PM Page 18

AIRPORT SAFETY

Airport operator espouses practical approach to safety management

One strategy for ensuring success is to implement a basic safety management system in stages and gradually win over the trust of operating personnel and management

The first steps in a process that processes that already were in place at THOMAS LAU CHRISTENSEN required that CPH change its approach to Copenhagen Airport. Integrating these COPENHAGEN AIRPORTS A/S safety were taken by the aerodrome man- practices within the SMS eased the intro- (DENMARK) ager and the operator’s senior manage- duction of the system. ment. Before proceeding, it was critical to To develop and then implement an VER the past few years the focus demonstrate that senior management SMS in accordance with CPH’s stated Oon safety management and safety openly supported the entire process for philosophy, a working group was formed, management systems has sharp- developing and introducing an SMS. The chaired by the newly appointed safety ened distinctly. There have been numer- aerodrome manager then appointed a manager. The working group consisted ous articles on the subject, as well as safety manager to take charge of the training courses and conferences, but all process. Lastly, a number of activities this attention has ironically made the sub- were undertaken to encourage and pro- ject appear to be more complicated than it mote a positive safety culture. Among need be. Simply put, a functional safety these was a presentation about apron management system (SMS) enables an safety which was given to all ground han- organization to address safety issues in a dling agencies, including flight caterers. structured way. A total of 1,500 persons, all working air- A practical approach to safety, such as side, have attended the presentation so that adopted by Copenhagen Airports far, and as a result there has been a A/S (CPH), the aerodrome operator at noticeable improvement in airside safety Copenhagen Airport, can be effective consciousness. without being complicated. Copenhagen’s One reason the first steps were so experience, which stresses the impor- important was because they underscored tance of comprehensibility, might serve a sincere desire by management to as an example for other aerodrome oper- change CPH’s safety philosophy. Instead ators that are uncertain about how to of simply reacting to safety concerns, manage safety. safety was to be approached in a more Copenhagen Airports A/S, like many formal, systematic and proactive manner. other international airport operators, From the beginning, CPH management n e s

recently established an SMS to comply mandated that the SMS must be practical, r e t e

with an airport certification requirement effective and easily understood by staff. In P . V

that ICAO introduced in 2001. other words, the system had to be kept sim- e n r CPH began developing its safety man- ple. This quality has proven to be the most A agement system in January 2005. From important criterion for success, encourag- mainly of operational personnel and the earliest stage there was a dialogue ing the staff and managers together to reported to a steering committee, which between the Danish Civil Aviation claim ownership of the system. An “easy to was chaired by the aerodrome manager. Administration (DCAA) and the airport understand” mantra that governed the When CPH initiated this process, management. Recognizing that a safety development and implementation process extensive guidance material on safety management system can hardly be imple- proved crucial, for under no circumstances management was available, but guidance mented overnight, the DCAA agreed with could CPH allow the process to result in a relevant to airport operation was very CPH on what kind of documentation mere theoretical study. limited. Although the Manual on should be provided in order to qualify for In keeping it simple, as much as possi- Certification of Aerodromes (ICAO a renewal of its aerodrome certificate. ble CPH has adapted safety management Document 9774) outlines the require-

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AIRPORT SAFETY

ments for an aerodrome operator’s safety ence on safety at Copenhagen Airport. and requirements. DCAA approval for the management system, it does not provide While essential, a policy is still only a manual was granted prior to 24 specific guidance on its implementation. statement, and it cannot have effect November 2005, the ICAO deadline for The newly released Safety Management unless it is supported by concrete work having an SMS in place. Manual (ICAO Document 9859) may be processes and requirements that are col- regarded as a comprehensive reference lectively known as safety strategy. Hence, Implementation process for airport operators, but this source was the safety strategy outlines the tactics to CPH is in the midst of implementing not at hand in early 2005, and with little be used to realize the goals articulated by the 12 strategic principles, which direction, CPH decided to develop an SMS the policy. inevitably will have an impact on current based on the industry’s best practices. CPH’s safety strategy is based on 12 work procedures. Besides introducing The foundation of the CPH safety man- strategic principles that fall under three changes to daily routines, the implemen- agement system is a policy that spells out broad categories, namely to achieve, to tation process also calls for the commit- CPH’s safety management goals. The maintain, and to improve on a high stan- ment of organizational resources. Thus, draft policy was presented to the CPH dard of safety. to ensure a successful and practical Board of Directors early in the develop- CPH’s safety management system is implementation, CPH has adopted a prin- ment process, as high-level approval was depicted in the accompanying table (page ciple-by-principle approach. required to confirm the direction that 20). Much thought has gone into the Why not just implement all of the prin- CPH should take. development of the system, since it was ciples instantaneously and obtain safety The CPH safety policy calls for the air- important to ensure it could be easily benefits from Day One? There is no short

View of Copenhagen Airport’s Terminal 3. The airport operator expects to fully implement a safety management system by the end of 2007.

answer to this question. However, to cre- ate actual safety benefits, both short- and long-term, it is vital first for staff and man- agement to become the custodians of the safety management system. While building trust among staff mem- bers cannot be achieved in a day, it is essential to eventually win their confi- dence. Without this, the SMS is destined to fail very early in the implementation effort. Possible resistance from those who might view the SMS as just “another bureaucratic management system” would be detrimental to the objectives. Because the SMS imposes new requirements on some work routines, a new level of competence is imperative. For example, the most radical change is the requirement to complete risk assess- port operator to work in a systematic, understood. It is believed that the final ments. For this to be done properly, train- structured and proactive manner to layout of the SMS is very pedagogical. ing needs to be provided, and of course achieve its overall safety goal, which is CPH opted to document the SMS in a training takes time. to reduce the probability of an incident standalone publication rather than as part An SMS implementation plan was at the airport. This goal goes a step of the aerodrome manual. The manual is developed detailing the sequence for beyond the industry’s best practices, deliberately concise since personnel introducing the strategic principles. The which focus on reducing the probability might be discouraged from using a large initial focus has been on three of the prin- of an accident. document. The CPH Safety Manual allo- ciples, specifically the reporting and If considered in isolation, of course, cates one page for elaborating each prin- analysis of safety occurrences, the defini- CPH’s safety policy cannot exert an influ- ciple, describing the related processes tion of safety levels, and risk assessment.

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AIRPORT SAFETY

These principles were selected for their in the surrounding environment. In addi- undesirable trends. According to the tactical advantages, since they provide the tion, a significant period of time must be Danish regulatory requirements for safe- organization with positive safety benefits devoted to the effort to infuse the safety ty management systems, responsibility at an early stage of SMS implementation culture among all airport personnel. for internal investigations of safety occur- without being a burden on resources. To facilitate implementation within the rences also rests with the safety manager. Moreover, obtaining early safety benefits organization, CPH arranged for a number An important detail is to establish clear helps foster support among management of presentations on SMS and its impact. lines of responsibility for safety. Overlaps and staff. The three principles are also Individual meetings were held with man- or uncertainty about such responsibilities considered as precursors to implementa- agers who are accountable for specific must not be allowed to exist. To ensure that managers are accountable for safety, CPH has begun to document all of their SAFETY POLICY safety responsibilities, a major task as it involves defining accountability at the SAFETY STRATEGY senior management level down through the organization to individual staff func- tions. So far, CPH has defined the roles of ACHIEVING A HIGH MAINTAINING A HIGH IMPROVING THE STANDARD OF SAFETY STANDARD OF SAFETY STANDARD OF SAFETY the aerodrome manager as well as senior Means to achieve Means to maintain Means to improve safety and middle-level management. a high level of safety a high level of safety Occurrence reporting and analysis. As ORGANIZATIONAL CONTROLLING CREATING A CONTINUOUS early as 2001, the DCAA had established ELEMENTS SAFETY RISKS IMPROVEMENT OF SAFETY ALLOCATION OF SAFETY AUDIT OF SAFETY CULTURE a mandatory and non-punitive occur- RESPONSIBILITY PERFORMANCE SETTING SAFETY GOALS Ensuring an unambiguous Safety performance shall Safety goals shall be defined to rence reporting system, thus taking the distribution of safety responsibility. be audited internally. ensure a continuous improvement first step to create a just safety culture of safety. COMPETENCE AND SAFETY TREND MONITORING QUALIFICATIONS Flight safety shall be monitored to PROPOSALS FOR within Denmark’s aviation industry. Ensuring qualified, motivated and identify undesirable safety trends. IMPROVING SAFETY competent personnel. All personnel are obliged to focus Stakeholders are obliged to report all on improving flight safety. EXTERNAL SERVICES DOCUMENTATION OF safety-related occurrences to the DCAA. External suppliers and associates SAFETY ACTIVITIES shall comply with safety standards DOCUMENTATION FOR In return, the reporter is protected from defined by CPH. IMPLEMENTATION OF disciplinary action or punishment by the SAFETY INITIATIVES SAFETY ACTIVITIES Documentation shall verify that non-punitive policy. Without a positive safety initiatives are implemented SAFETY LEVELS (e.g. corrective actions and Quantitative safety levels shall be safety culture in place, occurrence risk mitigations). established when possible. reporting would be restrained and CPH DOCUMENT AND DATA CONTROL RISK ASSESSMENT All safety documentation shall be All changes shall be risk assessed. would have insufficient means for ade- recorded and controlled. REPORTING AND ANALYSIS OF quately monitoring safety at the airport. SAFETY OCCURRENCES All safety occurrences shall be A number of reporting systems had reported and analysed internally at CPH. already existed at the airport when the process of developing SMS began. These The safety management system developed by Copenhagen Airports A/S is based on included reports on airside security, bird 12 strategic principles control, foreign object damage (FOD) tion of the other nine principles. For safety performance. Support has been and runway inspections. At the time, example, without reports on safety occur- provided by a number of key personnel most reports were used individually to rences (a goal of the first principle) it appointed from each department. In addi- assess the current state of a specific prob- would not be possible to perform safety tion, risk assessment training courses lem, and were not used systematically trend monitoring, nor would it be realistic have been held internally, and some per- and collectively — in a proactive manner to ensure that defined safety levels are sonnel have received accident and inci- — to recognize significant safety trends. achieved or to set new safety goals. dent investigation training. Considered as a whole, Copenhagen With CPH’s incremental approach to Organizational elements. The appoint- Airport is a complex entity, with more SMS implementation, it is envisaged that ed safety manager fills a support function than 20,000 persons distributed among all 12 strategic principles will have been for the CPH aerodrome manager. 400 companies involved in its operations. put into effect by the end of 2007. After Besides being responsible for develop- On such a scale it is difficult to establish reaching that milestone, development of ing, implementing and maintaining the a singular reporting system that will the SMS will not cease entirely. The SMS safety management system, the CPH work. Having this as the ultimate goal, is perceived as a living mechanism that safety manager must ensure that the CPH decided to use the information needs to continually adapt to the changes aerodrome manager is aware of any available from existing reporting sys-

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tems in order to avoid disrupting the was derived from the ICAO model, and this period Copenhagen Airports A/S will reporting process. uses a scale ranging from AA (Aircraft conduct internal risk assessment courses CPH developed a basic database to log Accident) to E (Not Determined). to ensure that relevant personnel are com- all safety occurrences. These data will be Safety levels. It was decided early in the petent enough to make the assessments, used in the future to perform trend mon- implementation process to not define and which will be based on qualitative, instead itoring, one of the organization’s strategic publish an overall quantitative level of of quantitative, data. It will also develop principles and another element of SMS. A safety, at least not for the present. The practical material to guide staff in per- daily drill has now been established to organization does not yet possess either forming their daily work regimen. review all incoming reports with the pur- the expertise or extensive knowledge The responsibility for making risk pose of highlighting significant occur- base needed to define an overall quantita- assessments currently rests with the proj- rences. All occurrences are assessed and tive level of safety. Instead, CPH relies on ect manager and/or the manager respon- classified in terms of their impact on safe- a top-ten list of the most significant safety sible for the particular airside activity. ty using an occurrence severity classifica- risks, enumerated in order of priority. tion scheme. Subsequently, they are The risks are discerned using information Route to success analysed with the aim of deciding from existing reporting systems and trend Based on the experience gained by whether to undertake an investigation. monitoring. For each risk, a goal is defined CPH in implementing its SMS, these are The objective of such investigations is as well as a roadmap for a few key recommendations to identify what went wrong in a particu- reaching the goal. Examples Risk assessments that other aerodrome opera- lar incident and determine how a reoc- of risks identified are runway are an important tors might consider in the currence can be prevented. The purpose incursions, problems associ- event they are just beginning is not to allocate blame, as this is con- ated with FOD, and taxiway means of ensuring this process. trary to the goal of creating a just safety incursions. proactive safety • Do not reinvent the wheel. culture. The investigative process takes Available data are being Extensive literature is avail- management on a wide perspective with the intent of reviewed to ensure that the able on the subject of safety addressing the specific cause of the priority list is up-to-date, management systems, includ- occurrence. along with the associated goals and ing information tailored to the aviation An Airside Safety Task Force has been roadmaps. Once fully implemented, the industry. ICAO’s newly released Document established by Copenhagen Airports A/S. list will become integrated in the daily 9859 is a comprehensive work of reference. This is chaired by the safety manager, who management of the airport. Adopt what is known as best practices is in direct contact with the aerodrome A primary requirement when defining and integrate this into the current organi- manager. The intention of the new task goals is to ensure that they are practical zation’s regimen. It is important to pres- force is to conduct incident investigations and measurable. In addition, sufficient ent safety management as a tool focused and recommend corrective actions. The data needs to be on hand. on improving flight safety at the aero- members are selected on the basis of their Risk assessment. The requirement for drome. An SMS uses many of the same in-depth knowledge of specific operational risk assessment represents the most rad- principles found today in quality manage- or technical fields. Five of the task force’s ical change associated with a safety man- ment and environmental management 11 members have attended incident inves- agement system. Risk assessments are systems. The aerodrome SMS has a tigation training courses. an important means of ensuring proactive proactive approach to aviation safety; that The Runway Safety Team has also safety management. With this element in is, it focuses on accident prevention been established. This is chaired by the place, no change affecting the airport’s rather than preventing reoccurrences fol- aerodrome manager, with representa- operation may proceed without a risk lowing an aircraft accident. tives from the air traffic services (ATS) assessment showing that all risks are • Ensure senior management support. The provider and domestic air carriers. The maintained at an acceptable level. Where decision to implement an SMS must be focus within the team is to reduce the this is not the case, an appropriate means taken by senior management, and must be number of runway incursions at of mitigating the risks must be found. based on a sincere desire to work proac- Copenhagen Airport. If not implemented and then controlled tively to advance safety and not simply a With only limited guidance material properly, the introduction of risk assess- wish to fulfil a regulatory requirement. available to aerodrome operators when ments may jeopardize the successful appli- Management support is essential, as SMS CPH began introducing its SMS, the cation of the safety management system, introduces procedures that have an effect organization opted to develop its own especially considering the system’s direct continued on page 40 aerodrome occurrence severity classifica- impact on daily work routines. CPH has tion scheme for classifying the impact of therefore planned the year-long imple- Thomas Lau Christensen, the Safety Manager for Copen- hagen Airports A/S, has been a speaker at recent ICAO occurrences. The structure of this scheme mentation process very carefully. During seminars on runway safety and ATS safety management.

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ATM SAFETY

Implementation of ATM safety management systems remains a priority for Europe

Following two serious aircraft collisions in recent years, European States have intensified their efforts to improve safety in the area of air traffic management. Central to this effort is the widespread promotion of the principles of safety management.

plying with ACAS resolution advisories,” Regulatory context EUROCONTROL Issue 5/2004, pp 18-20). Not since 1976 Since the early 1990s Europe has had Europe suffered such disasters. sought to ensure strong safety oversight LTHOUGH aviation is among Eurocontrol took immediate action to by separating safety regulation from its the safest means of transport, address the safety issues arising from management, and by instilling safety A risk is a constant reality — as is these accidents. It instigated a pro- within a gate-to-gate concept. This frame- true with any human activity — and the gramme to raise awareness of ATM safe- work has allowed European States to fact remains that any aviation operation ty requirements and to speed up imple- develop ATM safety systems based on a can lead to an accident. mentation of ATM safety management common, agreed format. To promote safe operations, ICAO has systems across Europe. With respect to ATM, safety regulation developed many standards and recom- Eurocontrol is actively involved in is based on a core structure of six mended practices (SARPs), and other improving the safety of ATM operations Eurocontrol safety regulatory require- organizations, such as Eurocontrol, in European airspace. Indeed, much work ments (ESARRs). ESARRs and other EU develop regulations and issue guidance has been done over the past decade or so rules require that States take certain material for their implementation. to enhance ATM safety by harmonizing actions to ensure that safety systems are However, despite every effort to enhance — as far as possible — airspace struc- developed in a controlled way, with a air safety, accidents still occur. ture, ATM procedures and technology. common baseline. Safety systems must Early in this decade serious accidents in This work has been undertaken in coop- also form the basis for oversight of the Europe served as a wake-up call to do eration with the European Civil Aviation ATM system. The foundation for the more to enhance air traffic management Conference (ECAC), an inter-govern- development of the European ATM safe- (ATM) safety. In October 2001, a runway mental body set up in 1955 to promote ty framework, ESARRs complement and incursion at Milan’s Linate Airport caused the continued development of a safe, effi- often exceed ICAO standards. heavy loss of life (see “Numerous factors cient and sustainable European air trans- In addition, ECAC member States are contributed to fatal runway incursion at port system. audited by Eurocontrol. The audits focus Milan Linate Airport,” Issue 2/2004, pp 18- Recent ATM safety enhancements in on the timely, uniform and effective 19); in July 2002, a mid-air collision Europe have been achieved through sev- implementation of ESARRs at the State occurred over Germany (“Accident report eral programmes requiring the collabora- level, as well as on the safety oversight underscores critical importance of com- tion of ECAC member States. The current capability of States in terms of air traffic strategy foresees many changes in management. This latter activity is

100 the way airspace is managed and aligned with the safety oversight audits much closer cooperation between that are conducted by ICAO. To minimize 80 European States. Recently, the any overlap between the Eurocontrol and

60 European Union (EU) launched a ICAO audits, the two organizations work legislative initiative to create a in unison, having signed a memorandum 40 2002 “Single European Sky” (SES), a of cooperation in 2005. 2004 Maturity Score (%) development that will eventually In Europe, the progressive separation 20 2006 mean that the airspace over EU of the provision of air navigation services 0 member States will be treated as a (ANS) from other government activities 0 0.2 0.4 0.6 0.8 1 State number divided by number of participating ANSPs single continuum (see box, page has led to the establishment of agencies 23). This concept will have implica- and corporations, both publicly and pri- Figure 1. ATM safety frameworks implemented tions for the way that air traffic man- vately owned, operating in an increasing- by service providers within ECAC States have matured significantly in recent years agement in Europe is regulated. ly market-orientated way. This, in turn,

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has given rise to the emergence of nation- EUROCONTROL al or regional bodies needed to regulate Workshop(s) Agency

this new ATM environment. Identification of Identification actions required Draft Identification of Organize The European Commission has also of awareness e.g. coordination procedure(s) training needs requirements with regulator Facilitate signalled its intention to expand the role or consultation with staff of the European Aviation Safety Agency

(EASA) to include ATM and airport safe- Field activities ty regulation. Since September 2003, Carry out Conduct actions required when it became operational, EASA has Published Get the Follow-up of awareness e.g. coordination procedure(s) training done with regulator Help Desk taken over several regulatory functions initiatives or consultation with staff previously exercised by the national civil aviation administrations of EU member States. Although its role expansion will Next step FEEDBACK not occur for a few years yet, preparation of the essential requirements for ATM Figure 2. The SASI Project was designed to help ANS providers implement the basic has now commenced. To ensure a com- elements of an SMS prehensive approach, Eurocontrol is tem (SMS) in place, while ESARR 3 specifi- tion measures. The SMS must provide establishing working links with EASA to cally requires that Eurocontrol member consistent, efficient and practical support manage ATM safety regulatory issues States (and ECAC member States on a vol- for organizational projects as well as within the context of current institutional untary basis) ensure that all service demonstrate regulatory compliance. It responsibilities. providers have an SMS in place. must support effective operations while An SMS provides a management struc- adequately addressing safety. With an Safety management systems ture within which safety roles and respon- SMS in place, safety improvements are Safety may be defined as the state in sibilities of organizations and individuals continuously identified and prioritized. which the risk of harm to persons or are clearly set out. Guidance is given to In early 2006 ICAO issued the first edi- property is reduced to, and maintained at managers on how their responsibilities are tion of its Safety Management Manual, a or below, an acceptable level through a best put into practice, and best practices document aimed at all sectors of the avia- continuing process of hazard identifica- are identified. Training requirements are tion industry. For ATM it covers not only tion and risk management. set down and the use of safety tools, such the actions required by service providers, In the past, aviation safety has focused as risk assessment, is explained. but also those entities involved in acci- on compliance with an increasingly com- An SMS is required to make safety an dent investigation and safety oversight. plex set of regulations whose implemen- explicit activity within an organization. It The document lists many important fac- tation was overseen by regulators. While serves to systematically identify all safety tors in the overall management of safety. this situation still exists, the steady risks and implement appropriate mitiga- No single factor will meet today’s expec- increase in air traffic means that the tations for risk management, but an number of accidents can be expect- integrated application of most of the SINGLE EUROPEAN SKY ed to rise even if the accident rate factors will increase the aviation sys- does not change, a situation that tem’s resistance to unsafe acts and calls for systematic and structured MUCH PUBLICITY has been given to the forma- conditions. safety management. To maintain a tion of the Single European Sky that will trans- Failure to implement a robust publicly acceptable level of risk form the currently fragmented approach to air safety management system could despite increased activity, the air- traffic management in Europe. It is anticipated result in safety activities not being craft accident rate must be reduced, that in the longer term this will lead to fewer serv- carried out, or being carried out at a goal that can only be met by adopt- ice providers and therefore fewer air traffic con- the wrong time or at high cost. If this ing a more proactive approach to trol units. were to occur, the accident rate may safety. Eurocontrol is providing support to the not decline. Risk is best managed by implement- European Commission in drawing up the meas- ing a dedicated system for managing ures for implementing the Single Sky regulations. Safety enhancement safety. Both ICAO and Eurocontrol Eurocontrol is also providing harmonized guid- As a direct result of the aircraft recognize the importance of this. ance and direct support to States, national super- collisions cited above, Eurocontrol ICAO Annex 11 requires that air traf- visory authorities and ANS providers to help instituted a review of ATM safety fic services (ATS) providers world- continued on page 40 within ECAC member States. This wide have a safety management sys- study led to three fundamental con-

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clusions: firstly, that leadership and com- nificantly, as illustrated in Figure 1 (page 22). ments and develop an action plan. mitment to safety in many States — for A number of activities related to these The working sessions are labour inten- both regulation and safety management safety programmes, as described below, sive, and highly interactive, so that expe- — needed to be strengthened; secondly, contribute to the overall aim of fully riences and ideas can be shared. Twenty- that resources, particularly trained and implementing a European ATM safety one ANS providers participated in the qualified personnel, required bolstering; framework. working sessions to the end of 2006. and thirdly, that the level of implementa- SMS implementation support for ANS Activities for 2007 are already planned, tion of ATM safety management systems providers. In 2004, as part of its strategic with one phase of the project set to be across Europe was uneven. It was also safety action plan, Eurocontrol launched completed in June 2007. In addition, concluded that until those issues had a project to provide support to ANS beginning in May 2007 a specific SASI ini- been resolved, little substantial progress providers. The main objective of the SASI tiative is planned for five more ANS could be made on other issues. Project, as it is known, is to help service providers over the 2007-09 period. A strategic action plan was drawn up to providers implement the basic elements Field implementation and support. Once enhance safety in areas where it would of an SMS. This is a fundamental step in back within their own organizations, safe- have the most direct impact and, in partic- enhancing ATM safety in the ECAC area, ty managers are expected to apply their ular, the areas highlighted by the two and currently support is being provided action plan (after its approval by their major accidents. There were some techni- to service providers in 21 ECAC member organizations). Further support may be cal issues, too: It was found, for example, States, with more planned for 2007. required from Eurocontrol during field that some guidance material for airborne The SASI Project consists of a series of implementation, the last and most delicate collision avoidance system (ACAS) proce- working sessions followed by a 16-week phase of the SASI Project, as safety man- dures was unclear, and in some instances long field implementation in the ANS agers may be involved in numerous other misleading. Early action was therefore provider’s own environment, with sup- tasks and may also lack adequate taken, in conjunction with ICAO, to port from Eurocontrol experts. It aims at resources. improve that situation. Ground-based safe- achieving basic ICAO Annex 11/ESARR By the end of January 2006, ATM safety ty “nets,” particularly the short term con- 3 compliance (as a first step) by mid-2007. frameworks within Europe had on average flict alert (STCA), were also addressed The first SASI activities cover the achieved 70 percent of full implementation. because the appropriate standards and development of a meaningful and cus- The objective is to raise safety systems in guidance material were not yet in place. tomized safety policy, the implementation all States in Europe to at least 70 percent Since 2002, much work has been under- of the fundamental principles of safety implementation by the end of 2008. taken by Eurocontrol on both occurrence reporting, inves- Incident reporting. An integral part of airborne and ground-based Before SES can tigation and competency, any SMS is a comprehensive occurrence safety protection, which will become a reality, and lastly the progressive reporting system, since hazard identifica- result in the introduction of introduction of safety assess- tion is a critical step in managing safety. European standards for robust safety ment and surveys (see Each hazard identified must be evaluated ground-based safety nets dur- management Figure 2, page 23). and prioritized, a process that requires the ing 2007. However, funda- This approach requires a compilation and analysis of all available systems must be mental to the enhancement strong commitment from data using appropriate analytical tools. of aviation safety in Europe put in place by all the management at each With this information about hazards, risks was a heightened awareness service providers service provider, notably by are identified, assessed and finally man- of ATM safety requirements encouraging and supporting aged. A database may be required to facil- and the importance of intro- designated safety managers itate the storage and retrieval of informa- ducing an ATM SMS. in implementing the recommended tion, and a safety “cycle” needs to be estab- Eurocontrol’s objective is to raise the actions. It also relies on a timely imple- lished to ensure that identified risks are level of SMS implementation across mentation of the recommended actions managed properly. Europe to at least 70 percent of the safety by individual ANS providers. States are required by ICAO Annex 13 requirements being met. To that end, a SASI working sessions. One-week work- to establish a mandatory incident report- strategic safety action plan was in effect ing sessions are organized at Euro- ing system to facilitate the collection of from February 2003 until the end of control’s Brussels headquarters for each information on actual or potential safety January 2006, an initiative that was fol- SMS element to be implemented. Safety deficiencies. They are also encouraged to lowed by a new European safety pro- managers have the opportunity to devel- establish a voluntary incident reporting gramme for ATM. With the strategic safe- op their own draft procedures, identify system and adjust their laws, regulations ty action plan in effect, ATM safety frame- awareness requirements and associated and policies in such a way as to encour- works within ECAC States matured sig- key messages, identify training require- age reporting.

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ATM SAFETY

As highlighted by a 1998 Eurocontrol lines and service providers. All of these things, been adopted for the European report on ATM performance, “significant factors have had the cumulative effect of Safety Programme for ATM, and a safety variations exist in the scope, depth, consis- reducing the level of reporting and there- data analysis function for ATM occur- tency and availability of ATM safety data” fore information sharing. rences is now being established in con- across the ECAC area. The report under- Such issues have been addressed by junction with the European Coordination scored the fact that achievement of consis- Eurocontrol by setting up a task force in Centre for Aviation Incident Reporting tent high levels of aviation safety and ATM 2005. It concluded that while changes to Systems (ECCAIRS), the Europe-wide safety management required the effective current legislation were not required to database for all aviation occurrences. use of harmonized occurrence reporting protect safety data, there did exist consid- However, the European ATM community and assessment schemes. Harmonized erable variations in the approach of judi- still needs a risk warning system support- schemes would lead to more ed by a common safety infor- systematic visibility of safety mation repository. occurrences and their caus- The question of legal impe- es, and would highlight the diments is being addressed appropriate corrective actions by opening a dialogue with and areas where safety could the judiciary and by holding be improved through chan- ad hoc workshops. Euro- ges to the ATM system. control has also issued guid- Harmonized schemes would ance material on establishing also provide the data needed a just culture to complement to operate an SMS. The ESARR 2. report led to the publication of ESARR 2, a regulation con- Summary cerning the reporting and Serious accidents in recent assessment of safety occur- years have caused European rences in ATM, and an ATM ATM authorities to review safety database. Moreover, Eurocontrol’s efforts to accelerate implementation of ATM safety the status of ATM safety the EU has issued a directive management systems across Europe are motivated in part by the frameworks across the 42 safety challenge posed by the continent’s steady growth in air traffic on occurrence reporting in States of ECAC, and to put in civil aviation, and set up a database for cial systems. In some States, good prac- place a programme to advance implemen- information collected through the require- tices were supported by appropriate leg- tation of such frameworks, where neces- ments set out in the directive. islation, but sometimes good practices sary. By early 2006, half of the service Over the past few years European were still embedded within an ambiguous providers across Europe had established States and ANS providers have made con- legislative framework, and sometimes safety management systems whose level siderable progress towards implementing neither the good practices nor the neces- of maturity exceeds Eurocontrol’s imple- incident reporting schemes. However, the sary legislative framework were in place. mentation target. process is still not comprehensive, and the The Eurocontrol task force also con- As an outgrowth of efforts to improve quality of the data still varies significantly cluded that in a significant number of ATM safety in Europe and encourage from country to country. Despite the clear cases the credibility of safety regulation, States and service providers to ensure benefits of sharing information, some including the oversight of safety reporting robust safety management systems have States and ANS providers remain con- and assessment processes by States, is been put in place, Eurocontrol and ICAO cerned that their safety record might be threatened by a lack of human and finan- are cooperating more closely on ATM compared unfavourably with others. cial resources. A number of its recommen- safety matters. The ICAO regional office A “just culture.” In addition, ATM pro- dations concentrated on getting States to in Paris and Eurocontrol are working fessionals have expressed concern about adapt their national legislative frameworks together to help ICAO member States of public perception and especially the atti- to foster a “just culture,” improve staffing tude of the judicial system. There is grow- levels, raise awareness of the reporting continued on page 36 ing concern about the occasional inter- requirements, and disseminate best prac- The European Organization for the Safety of Air Navigation (Eurocontrol) develops, coordinates and vention of the legal system, a trend that tices. The group encouraged Euro- plans for implementation of pan-European ATM strate- engenders fear of sanctions among control’s governing bodies to take a lead gies and their associated action plans in a collective effort with all stakeholders. The primary objective reporters. Furthermore, certain media in improving the situation. of the organization, which currently numbers 37 have dealt unsympathetically with appar- The recommendations of the Euro- member States, is the development of a seamless ATM system across Europe. For more information, visit ent breaches of safety within certain air- control task force have, among other www.eurocontrol.int.

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DATA PROTECTION

Guidance material addresses concerns about protection of safety information

Legal guidelines developed recently by ICAO focus on enactment of national laws and regulations that safeguard data collected for safety purposes while also allowing for justice to take its course

incident investigations has long formed in time to deal with them appropriately. SILVÉRIO ESPÍNOLA • MARCUS COSTA the backbone of activities aimed at Moreover, since accidents and incidents DANIEL MAURINO improvements in equipment design, main- represent failures of the aviation system, ICAO SECRETARIAT tenance procedures, flight crew training, human performance data obtained air traffic control systems, airport design through investigations inevitably reflect NTERNATIONAL civil aviation’s out- and functions, weather support services, unsuccessful system and human per- standing safety record is largely attrib- and other safety-critical aspects of the air formance, or what might be called unmit- I utable to the dedication to safety transport system. In recent years, techno- igated operational errors. shown by aviation organizations and their logical advances have led to an accelerated On the other hand, a typical aviation personnel. Equally important is a continu- development of safety data collection, pro- operation – not unlike any human activity – ous learning process based on the devel- cessing and exchange systems. Safety involves frequent, minor and, most impor- opment and free exchange of safety infor- data collection and processing systems tantly, inconsequential errors such as mation, as well as industry’s ability to turn (SDCPS) form the pillars of a safety man- selecting wrong frequencies, dialling wrong altitudes or acknowledging incor- rect read-backs. Some of these types of errors reflect natural limits in human per- formance, while others are fostered by systemic shortcomings, but most are a combination of both. Nevertheless, the fact remains that these frequent and minor errors have the same damaging potential as rare and major errors underscored by accident and incident investigation. Fortunately, the damaging potential of minor errors is mitigated by the success- ful coping strategies employed by operat- ing personnel and the protective role of specific system defences that act to con- n o s tain errors. Emerging SDCPS systems n e g

r capture successful coping strategies and o J m

i effective system defences. Simply put, J Safety data collection and processing systems highlight successes in mitigating they highlight what works well in the operational errors and can therefore lead to more insightful conclusions about safety operating sphere. operating errors into preventive actions. agement system (SMS), and generate Countermeasures to operational errors Endeavours aimed at improving avia- information that is used to implement cor- are best developed by combining the les- tion safety must build upon empirical rective safety actions and proactive, long- sons gleaned from occurrence investiga- data. Fortunately, there are several term strategies. tions with information about successful sources of such data available to the avia- Accidents and serious incidents are strategies and defences obtained from tion community. In combination, these rare occurrences, usually reflecting the safety data collection and processing sys- sources of information provide the basis interplay of circumstantial factors. It is tems. The latter systems rely on one of for a solid understanding of the strengths often difficult, when using information three methods for collecting data: self- and weaknesses of aviation operations. from the investigative process exclusive- reporting, electronic capture or direct Information gathered from accident and ly, to uncover unsafe operating practices observation. With few exceptions, such

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data programmes are voluntary in nature While promoting safety, it also denies directed ICAO to participate in efforts to and, without exception, confidential and immunity to violators. improve safety information reporting and non-punitive. Since they never cease func- In recent years, however, information sharing of information. tioning, emerging safety data collection from these systems has been used for dis- ICAO Annex 13, Aircraft Accident and and processing systems generate a great ciplinary and enforcement purposes and Incident Investigation, establishes (para volume of information to support safety has also been admitted as evidence in judi- 5.12) that information gathered by a safe- efforts, including long-term strategies. cial proceedings where criminal charges ty investigation — including statements All safety data collection and reporting have been brought against individuals from persons, communications between systems can highlight system and human involved in aviation occurrences. This persons involved in an aircraft operation, success in mitigating operational errors. trend is a concern, since the inappropriate medical and private information, cockpit Such systems lead to more complete con- use of safety data may hinder the develop- voice recordings and transcripts, and clusions about safety, thus enhancing ment and free exchange of information opinions expressed in the analysis of development of countermeasures to that is essential to efforts to improve avia- information — shall not be made avail- human error. tion safety. able for purposes other than accident or One example of an industry initiative to The civil aviation community has incident investigation unless the appro- collect safety data through voluntary repeatedly attempted to ensure the pro- priate authority for the administration of reporting is the Aviation Safety Action tection of safety data, with mixed success. justice determines that their disclosure Programme (ASAP). Flight data analysis Such efforts must strike a very delicate outweighs the adverse domestic and programmes such as the Flight Operations balance of interests between the need to international impact such action may Quality Assurance (FOQA) Programme protect safety information and the have on that or any future investigations. are based on electronic capture of safety responsibility to administer justice. A cau- Annex 13 also establishes (para 8.3) data. Examples of the third category of tious approach is necessary to avoid mak- that voluntary incident reporting systems SDCPS, involving direct observation of ing proposals that prove incompatible shall be non-punitive, and sources of personnel at work by specially trained with national laws and policies. information shall be protected. ICAO experts, are the Line Operations Safety Within ICAO, a number of provisions Annex 6, Operation of Aircraft (Part I, Audit (LOSA) and the Normal Operations address the protection of certain sources para 3.2.4) stipulates that flight data Safety Survey (NOSS). (For more on of safety information, among them an analysis programmes shall be non-puni- LOSA, see Issue 4/2002, a special edition Assembly resolution urging States to tive and shall contain safeguards to pro- dedicated to this topic. For details about ensure that national laws, regulations and tect sources of data. NOSS, see Issue 3/2004, pp 14-16.) policies comply with ICAO Annex 13. In ICAO provisions protecting certain International situation. Safety data col- addition, the ICAO Assembly has called accident and incident records are explicit lection and processing systems have made for voluntary and non-punitive reporting regarding their admissibility in judicial possible a deeper understanding of opera- systems to be implemented, and has proceedings. While this is the case for tional errors. Without ques- tion, in general operational errors in aviation are inadver- tent and involve well-trained and well-intentioned people who may err while conducting operations or maintaining well- designed equipment. For those rare situations involving sabo- tage or reckless misconduct, enforcement systems ensure that those responsible are held accountable. This two-prong approach, balancing enhanced under- n

standing of inadvertent oper- o s n e

ational errors with appropri- g r o ate enforcement of rules in J m i cases of misconduct, has J Legal guidance developed by ICAO is designed to prevent the inappropriate use of information served civil aviation well. collected solely for the purpose of improving aviation safety

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information obtained from cockpit voice As a first step in preparing these guide- proper administration of justice. Na- recorders and transcripts, similar protec- lines, States were called on to provide tional laws and regulations protecting tion is not evident with respect to infor- examples of their relevant laws and regula- safety information should prevent its mation obtained from emerging SDCPS tions relating to the protection of informa- inappropriate use. systems. In the absence of explicit word- tion obtained from SDCPS. Subsequently, The ICAO guidance material sets out a ing such as that contained in Annex 13, ICAO conducted an analysis of the submis- number of tenets related to the protection information from safety data collection sions received, seeking common threads of safety information. Safety information systems is protected by agreements and conceptual points. The legal guidance should, for instance, qualify for protection established by operators and service that resulted takes the form of a series of from inappropriate use according to spec- providers. However, the legal protection principles that has been distilled from such ified conditions that should include, but such agreements afford to laws and regulations. not necessarily be limited to, a commit- SDCPS information within Protection of As the guidance material ment to collect the information for explic- the different judicial systems qualified safety primarily relates to two chap- it safety purposes and to avoid any disclo- around the world is rather ters of ICAO Annex 13, the sure that would inhibit the continued difficult to ascertain. information most effective means of dis- availability of such information. Few States have promulgat- under specified seminating the information Protection should be specific for each ed national legislation protect- was through an attachment system by being based on the nature of conditions ing information obtained from to Annex 13. Consequently, the safety information it contains. In addi- self-reporting safety and elec- is a State’s notes were added to Chap- tion, a procedure should be established tronic safety data collection responsibility ters 5 and 8 of Annex 13, with to provide formal protection to qualified systems, and in some coun- a further note added to safety information in accordance with tries legal reform may be Annex 6 (para 3.2.4 of Part I), specified conditions. required to accommodate such legislation. referring to the legal guidance contained Safety information should not be used Moreover, protection of information from in new Attachment E to Annex 13. in a way that is different from the purpos- direct observation safety data collection The objective of the guidance material es for which it was collected. Further- systems is not currently addressed by leg- is to prevent the inappropriate use of more, its use in disciplinary, civil, admin- islation in any State. information collected solely for the pur- istrative and criminal proceedings should Since current ICAO provisions, as well pose of improving aviation safety. be carried out only under suitable safe- as international and national legislation, To provide States with the flexibility to guards provided by national law. do not sufficiently address the protection draft laws and regulations in accordance According to ICAO guidelines, excep- of information obtained from SDCPS sys- with their national policies and practices, tions to the protection of safety information tems other than certain accident and inci- the legal guidance is formulated in a way should only be granted by national laws dent records, in many States national leg- that can be adapted to meet the particular and regulations when there is evidence — islation may give inadequate protection to needs of the State. Following is a brief or whenever an appropriate authority con- such information. This has created the outline of the guidance material in terms siders that circumstances reasonably indi- need for legal guidance that covers the of its general principles, as well as its cate — that the occurrence was caused by protection of all relevant safety data col- principles of protection and the question an act legally defined as conduct with lection and processing systems, and that of public disclosure. intent to cause damage, or conduct with is the product of a cautious international Providing protection to qualified safety knowledge that damage would probably consensus. information under specified conditions is result, behaviour that is equivalent to reck- Legal guidance. ICAO has formulated part of a State’s safety responsibilities. less conduct, gross negligence or wilful legal guidelines that address concerns The sole purpose of protecting such infor- misconduct. about the protection of safety data. This mation from inappropriate use is to This principle would also apply when material was drawn up in response to a ensure its continued availability so that an appropriate authority determines that request by the ICAO Assembly, which proper and timely preventive actions can the release of the safety information is adopted a resolution in 2004 directing the be taken to improve aviation safety. The necessary for the proper administration

organization “to develop appropriate legal protection of safety information is not continued on page 40 guidance that will assist States to enact intended to interfere with the proper Silvério Espínola is the Principal Legal Officer in the national laws and regulations to protect administration of justice. Legal Bureau at ICAO headquarters, Montreal. Marcus information gathered from all relevant National laws and regulations protect- Costa is the Chief of the Accident Investigation and Prevention (AIG) Section in the ICAO Air Navigation safety data collection and processing sys- ing safety information should ensure Bureau; Capt. Daniel Maurino, of the Flight Safety tems, while allowing for the proper that a balance is struck between the (FLS) Section in the Air Navigation Bureau, is the Coordinator of the ICAO Flight Safety and Human administration of justice in the State.” need for protection and the need for the Factors Programme.

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Information gleaned from recent accidents provides basis for safety improvements

Final reports issued by investigation authorities, plus safety alert arising from the August crash of a regional jet transport, serve the aviation community by underscoring various safety issues

WHILE they may not be proactive in Helios Airways Flight 522 did not become aware of this fact.) As pro- nature, unlike the other tools associated On 14 August 2005, a Boeing 737-300 grammed, the aircraft levelled off at FL340 with a safety management system, reports operated by Helio Airways departed and continued on the route entered into of aircraft accidents and serious inci- Larnaca, Cyprus at 0607 local time for the flight management computer. dents continue to be a time-honoured Prague, Czech Republic, via Athens, At 0721, the aircraft flew over the KEA means of promoting safety, in part Greece. The aircraft was cleared to climb VOR, then over the Athens International because they present recommendations to FL340 and to proceed direct to the Airport, and subsequently entered the for change that could enhance safety, but RDS very high frequency omnidirection- KEA VOR holding pattern at 0738. At also because they alert managers and al radio range (VOR). As the B737 0824, during the sixth holding pattern, operating personnel to critical issues. ascended through 16,000 feet, the captain the Boeing 737 was intercepted by two F- Under ICAO Annex 13, States routine- contacted the company Operations 16s of the Hellenic Air Force. One of the ly forward copies of their reports of inves- Centre to report a take-off configuration F-16 pilots observed the aircraft at close tigations of fatal aviation accidents and warning and an equipment cooling sys- range, reporting at 0832 that the captain’s serious incidents to ICAO, which are tem problem (a warning horn had sound- seat was vacant, the first officer’s seat was then entered into the organization’s acci- ed and the avionics bay temperature occupied by someone who was slumped dent and incident reporting (ADREP) warning light had illuminated). The over the controls, the passenger oxygen system for trend analysis and risk assess- warning horn to which the captain had masks could be seen dangling, and three ment within ICAO, among other things. responded in fact motionless passen- The final reports on accidents of special concerned the cabin gers could be seen in interest are included in the ICAO altitude and was acti- their seats with oxy- Aircraft Accident Digest. vated by a lack of gen masks donned. Among notable accident reports pressurization. No external damage received in recent months was that of the Several communi- or fire was noted. The Helios Airways Boeing 737 crash near cations between the crew did not respond Athens, Greece in August 2005, dissemi- captain and the Oper- to radio calls from the nated by the Hellenic Air Accident ations Centre con- military escorts. Investigation and Aviation Safety Board cerning the prob- At 0849, the F-16 (AAIASB) in October 2006. Also of note lems confronting the pilot reported that a The digital pressure control panel of the was the report on a fatal Boeing 747 flight crew took place B737-300. The AUTO and ALTN posi- person (later deter- freighter crash at Halifax, Canada in over a period of tions provide automatic cabin pressure mined to be a flight October 2004, released by the eight minutes, end- control, while the MAN position allows attendant who held a manual control Transportation Safety Board of Canada ing as the aircraft commercial pilot’s (TSB) in June 2006. climbed through 28,900 feet. Thereafter, licence) not wearing an oxygen mask had Following are brief summaries of the there was no response to radio calls to entered the cockpit and occupied the cap- conclusions contained in these reports. the aircraft. The flight crew, who had not tain’s seat. At 0850, the 737’s left engine (Space constraints prevent reproduction donned oxygen masks, probably lost use- flamed out due to fuel depletion, and the of report findings and recommendations, ful consciousness as a result of hypoxia aircraft started descending. At 0854, two however, website links have been indicat- some time after their last radio communi- Mayday messages were recorded on the ed for readers who are interested in cation on the company frequency at 0620, cockpit voice recorder (CVR). reviewing the full report.) Also highlight- approximately 13 minutes after take-off. At 0900, at an altitude of approximately ed below is a safety alert arising from the (During the climb, passenger oxygen 7,100 feet, the right engine also flamed crash of a Comair Bombardier CRJ100 masks deployed automatically at an air- out. The aircraft continued to descend in the United States in August 2006. craft altitude of 18,200 feet, but the pilots rapidly and impacted hilly terrain at 0903,

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in the vicinity of Grammatiko, Greece, dent, among them the fact that the cabin freighter at Halifax International Airport approximately 33 kilometres north-west pressurization mode selector was not on 14 October 2004 underscores the need of the Athens International Airport. The placed on the automatic position follow- for better systems to ensure correct take- 115 passengers and six crew members on ing aircraft maintenance. Also noted were off speed and thrust, according to an board were fatally injured, and the air- the lack of cabin crew procedures (at the investigation by the Transportation craft was destroyed. international level) for addressing events Safety Board of Canada. The final report The AAIASB determined that the acci- involving the loss of pressurization and (No. A04H0004) is available at the TSB’s dent resulted from both direct and latent continuation of a climb despite the website (www.tsb.gc.ca./en/reports/air/ causes. Among the direct causes, the deployment of the passenger oxygen 2004/A04H0004/a04H0004.pdf). investigation determined that the crew did masks, and the ineffectiveness of interna- The MK Airlines B747 was being oper- not recognize that the cabin pressurization tional aviation authorities in enforcing ated as a non-scheduled international mode selector was on the manual position implementation of action plans that address cargo flight from Halifax, Canada to during performance of their pre-flight, the deficiencies documented in audits. Zaragoza, Spain. At about 0654 In the months fol- Coordinated Universal Time, 0354 Atlantic Altitude Rapid disconnect Rapid disconnect (1 000 ft) (moderate activity) (sitting quietly) lowing the accident, Daylight Time, MK Airlines Flight 1602 22 5 minutes 10 minutes the AAIASB made a attempted to take off from Runway 24 at 25 2 minutes 3 minutes number of interim the Halifax International Airport. The air- 28 1 minute 1 minute 30 seconds safety recommenda- craft overshot the end of the runway for a 30 45 seconds 1 minute 15 seconds tions that were ad- distance of 825 feet, became airborne for 35 30 seconds 45 seconds 40 18 seconds 30 seconds dressed to the U.S. 325 feet, then struck an earthen berm. 65 12 seconds 12 seconds National Transporta- The aircraft’s tail section broke away from The length of time an individual can maintain useful con- tion Safety Board the fuselage, and the aircraft remained in sciousness when suddenly deprived of oxygen is primarily (NTSB), the aircraft the air for another 1,200 feet before it related to altitude (Carlyle, 1963) manufacturer, the struck terrain and burst into flames. The before-start and after-take-off checklists Cyprus Air Accident and Incident Inves- aircraft was destroyed by impact forces (the selector had been placed on MAN tigation Board, Cyprus-based airlines, and and a severe post-crash fire. All seven during unscheduled maintenance). In the Hellenic Civil Aviation Authority crew members suffered fatal injuries. addition, the crew did not detect the rea- (HCCA). As a result of the investigation, The report concluded that the speed son for the activation of the cabin altitude the AAIASB noted, the U.S. Federal and thrust settings selected by the crew warning horn, apparently interpreting this Aviation Administration (FAA) issued an members in preparation for their flight to as a take-off configuration warning airworthiness directive requiring a revision Spain were incorrect for the weight of the instead; nor did they notice an indication of B737 flight manuals to reflect improved Boeing 747-244SF. of passenger oxygen mask deployment or procedures for pre-flight setup of the cabin The investigation found that the crew the master caution light. With the flight pressurization system and crew responses did not receive adequate training on the crew incapacitated by hypoxia, the aircraft to cabin altitude warnings and take-off or Boeing Laptop Tool, a computer pro- was flown by the flight management com- landing configuration warnings. gramme used to calculate the take-off puter and autopilot until the fuel was The report highlighted additional safe- velocity and power necessary in light of depleted, resulting in engine flameout and ty deficiencies related to maintenance factors such as fuel weight, payload and impact with the ground. procedures, pilot training, normal and environmental conditions. TSB investiga- Among latent causes cited by the emergency procedures, airline organiza- tors also found that crew fatigue and a AAIASB were deficiencies in the opera- tional matters, and safety oversight of dark take-off environment may have com- tor’s organization, quality management maintenance and flight operations. The pounded the likelihood of error. As a con- and safety culture, as well as the regulato- final report of the AAIASB included an sequence, the board called on Canadian ry authority’s inadequate execution of additional 11 safety recommendations and international regulatory authorities safety oversight. Also highlighted were addressed to Cyprus, the European to ensure that crews of large aircraft are the inadequate application of crew Aviation Safety Agency (EASA) and Joint alerted in time where there is not enough resource management (CRM) principles Aviation Authorities (JAA), and ICAO. power to take off safely. The board rec- and the ineffectiveness of measures The 164-page report may be reviewed ommended that “The Department of taken by the aircraft manufacturer in at the AAIASB website (www.rndt.eu/ Transport, in conjunction with ICAO, the response to previous pressurization inci- FINAL_REPORT_SB-DBY.pdf). U.S. Federal Aviation Administration, the dents involving the same aircraft type. European Aviation Safety Agency, and The AAIASB cited a number of factors MK Airlines B747 freighter other regulatory organizations, establish that could have contributed to the acci- The fatal crash of an MK Airlines continued on page 36

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ICAO UPDATE ICAO addresses security concern highlighted by failed terrorist plot

In the wake of the planned terrorist plot to sabotage several share the results of ongoing work in this area and to develop airliners over the North Atlantic, unveiled by U.K. authorities common approaches and best practices for the longer term. in mid-August 2006, ICAO has developed security guidelines Emphasizing the importance of cooperation with intelligence for screening liquids, gels and aerosol products to be carried agencies and regulators, ICAO has developed a point of contact in the passenger cabin, and the ICAO Council has recom- (PoC) network for rapidly sharing significant security information mended that member States implement these guidelines no on an international basis. The PoC network, which uses a later than 1 March 2007. secure website for communications, so far involves registered As a result of the new security concerns, the Council has participants in some 70 States. Those States that are not yet also decided to form a Secretariat study group to develop part of the network are being urged to join without delay. long-term, cost-effective and harmonious security measures Over the long term, ICAO intends to review and revise its that will not impact on the overall objective of safe and effi- security standards and guidance for dealing proactively with cient civil aviation operations. The new group, to be com- any emerging threat. It will focus on how to further enhance posed of members of the Aviation Security (AVSEC), the integrity of airside security, including screening of work- Facilitation and Dangerous Goods Panels as well as econom- ers and cargo, catering products and hold baggage, and the ic and industry experts, is expected to present its recommen- possible relevance of other security measures such as dations before the end of June 2007. behavioural pattern recognition. ■ The newly developed screening guidelines for carry-on liq- uids cover all gels, pastes, lotions, liquid and solid mixtures, Disclosure authorized and the contents of pressurized containers such as shaving A total of 82 ICAO Contracting States and two territories had foam. Under the new guidelines, the affected containers are agreed by 23 November 2006 to the disclosure of either their full restricted to a maximum capacity of 100 millilitres each even safety oversight audit report or an executive summary of the if only partially filled. Such containers should be placed in a audit report at ICAO’s website. The decision to release the transparent, resealable one-litre plastic bag that is then pre- results of ICAO safety oversight audits to the public was made sented for visual inspection at the screening point, with a limit by the world’s directors general of civil aviation at a safety con- of one bag per passenger. ference at ICAO headquarters in late March 2006. ■ Exempted from the new screening process are medications, baby milk and foods, and items related to a special dietary requirement, although an appropriate and proportionate means of verifying the nature of such liquids also needs to be available. The guidelines recommend exemptions for liquids purchased either at airport duty free shops or on board aircraft, provided these products are packed in a sealed plastic bag that readily reveals tampering and that displays a satisfactory proof of purchase on the day of the journey. A revised list of prohibited items, intended to deal with the threat posed by liquid, gel and aerosol products that may be used in improvised explosive devices, is also under develop- ment. The revised list is to be based partly on the work of the ICAO International Explosives Technical Commission (IETC), which recently evaluated carry-on substances having char- acteristics that could make them attractive for use in a terror- FIRST MEETING ist attack. The list of prohibited items is considered a com- The first meeting of the Commission of Experts of the Super- plex matter as it involves law enforcement, explosives tech- visory Authority of the International Registry was held at ICAO nologies, evaluation of trace detection equipment, training of headquarters from 6 to 8 November 2006 under the chair- security personnel, logistics and commercial considerations. manship of Laurent Noël (Switzerland). The commission The ICAO Council has also adopted a recommendation by advises ICAO Council on matters related to the registry, which explosives experts to encourage States to continue their was created by an international treaty — the Cape Town Con- efforts to develop appropriate processes and technologies vention and Aircraft Protocol — that came into effect in early for dealing with the real threat from homemade explosives, 2006. The registry is a central feature of the regime which will while in the meantime applying some form of control or reduce the risks of lending for aircraft financiers, banks and restriction on liquids through screening points. It called for other financing institutions involved in aircraft purchasing and the Ad Hoc Group of Specialists on the Detection of leasing, thus reducing the cost of credit. Explosives (AH-DE) to convene a workshop in early 2007 to

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SMS implementation leads to safety enhancement despite strong industry growth

Central to its efforts to respond more effectively to the needs traffic management systems and performance-based effi- and expectations of member States, ICAO is focusing on the ciency improvements. implementation of safety management systems designed to The Council President’s 2 November address to the U.S. achieve measurable results in aviation safety, ICAO Council Federal Aviation Administration (FAA) International Aviation President Roberto Kobeh González informed participants of Safety Forum elaborated on safety policy, including the shift an international safety forum in early November. toward increased visibility of safety information, a develop- The emphasis of ICAO’s first-ever business plan, the ment that “should encourage States to correct more quickly Council President explained, is performance-based pro- the safety deficiencies that remain in their aviation systems grammes and initiatives that “provide the greatest return on and make it easier for States and donors to provide more investment of limited human and financial resources, through rapid and more effective assistance to those that require working methods and management practices that lead to much needed financial or human resources.” identifiable results.” Safety management systems are one Mr. Kobeh González remarked that so far some 80 States such initiative, a means of enhancing safety despite challeng- have authorized ICAO to disseminate information on ICAO ing industry growth that strains safety oversight resources. safety oversight audits at its public website, and other States “Safety management systems are the most effective way are expected to join them. In any event, the results from all of responding to the need for effective supervision with a rel- ICAO safety oversight audits will appear in summary form at atively small workforce,” stated Mr. Kobeh González. “Many ICAO’s website beginning in March 2008, ushering in a new member States are implementing or exploring safety man- era of openness. agement systems to complement the existing regulatory “This is an unprecedented development in terms of structure. We encourage them to do so …”. increasing transparency and sharing of information among ICAO, the Council President added, offers concrete assis- States, as well as with the industry and the travelling public,” tance in the form of standards and related guidance material Mr. Kobeh González said. for establishing safety management systems, including a set In reflecting on the theme of the 2006 symposium, Safety of aligned safety management provisions for aircraft opera- from Top to Bottom, the Council President asserted that tions, air traffic services and aerodromes, as well as model safety demands “a firm commitment from senior manage- legislation to make it easier to implement SMS. ment of airlines, airports, service providers, manufacturers, Other areas in which ICAO is concentrating its resources regulators and all other stakeholders, no matter how small, are the development of global performance-based security for aircraft operations to be as safe as is humanly possible. measures amongst States; the pursuit of unified and coordi- “The commitment to safety must flow from the top like a water- nated measures to reduce civil aviation’s adverse impact on fall and permeate every part of an organization,” he asserted. the environment; and the implementation of harmonized air The Council President’s full address to the 3rd Annual FAA International Aviation Safety Forum is available at the ICAO website (www.icao.int). Also available at the website is the President’s address to the 27th Assembly of the Latin American Civil Aviation Commission (LACAC) in Panama City on 6 November. ■

Council elects VPs and committee chairmen for 2006-07 The ICAO Council has elected three vice-presidents to serve for the 2006-07 period. The newly appointed vice-presidents are: Igor Lysenko, Representative of the Russian Federation, as First Vice-President; Dr. Attila Sipos, Representative of Hungary, as Second Vice-President; and Julio Enrique Ortiz FUNDING GRANT Cuenca, Representative of Colombia, as Third Vice-President. ICAO received a grant of U.S. $405,000 from the Govern- The Council also elected the chairmen of the five Council ment of Canada during a brief presentation at ICAO head- committees for a one-year period. Those appointed are: Air quarters on 12 September 2006. The funding is in support Transport Committee, Silvia Gehrer (Austria); Joint Support of the ICAO/Canada Security Awareness Training Pro- Committee, Bong Kim Pin (Singapore); Finance Committee, gramme. Debra Normoyle, Director General of Security and Dr. Nasim Zaidi (India); Unlawful Interference Committee, Emergency Preparedness at Transport Canada, is seen Donald Bliss (United States); and Technical Cooperation presenting the grant on behalf of Foreign Affairs and Inter- Committee, Daniel Oscar Valente (Argentina). national Trade Canada to Mohamed Elamiri, Director of the The ICAO Council, the governing body of the organization, ICAO Air Transport Bureau. comprises representatives of 36 States elected by the ICAO Assembly. ■

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Symposium puts spotlight to participation by the wider aviation industry as well as other on ATC safety parties interested in air navigation and air transport perform- ance, among them financiers, consultants and members of the ICAO will hold a global symposium on threat and error man- academic community. Prominent moderators and speakers will agement (TEM) and the process for conducting a normal lead the discussion on immediate and future issues related to operations safety survey (NOSS) in air traffic control in the performance of the air navigation system. Washington, D.C. from 7 to 8 February 2007. Developed by More information, including registration procedures, is the ICAO Flight Safety and Human Factors Programme, the available at the ICAO website (www.icao.int/perf2007). ■ symposium is intended to assist States and air traffic servic- es (ATS) providers in their efforts to monitor safety during normal ATS operations as part of a safety management sys- Safety data system marks tem (SMS). Open to officials from civil aviation administra- 30th anniversary tions, ATS providers, airlines, training institutions and profes- The ICAO accident/incident data reporting (ADREP) system, sional associations, the event is being hosted by the U.S. which contains some 34,000 occurrence reports on aircraft hav- Federal Aviation Administration (FAA). ing a certificated maximum take-off mass of over 2,250 kilograms The symposium will highlight guidance material developed by (5,000 lb), has now been in use as a safety tool for 30 years. ICAO in recent years. With the assistance of a team of experts ADREP began in 1976 as a simple batch processing sys- known as the Normal Operations Safety Survey Study Group tem. Managed by the Accident Investigation and Prevention (NOSSSG), the organization developed a circular on the subject Section (AIG) of the ICAO Air Navigation Bureau, ADREP was of TEM in air traffic control which promotes safety management last upgraded in 2004 by implementing a data system specif- and provides training guidance. It has also developed a proto- ically developed for occurrence reporting. The same data col for conducting the normal operations safety survey, and has system, developed by the Joint Research Centre (JRC) of the arranged for several ATS providers to undertake NOSS trials. European Union, has been installed in several EU member The symposium will feature case studies based on the experi- States as well as a number of countries outside the EU, and ence with implementing NOSS; these will be presented by permits the reporting of data to ICAO electronically. Airservices Australia, Nav Canada, Airways New Zealand and ICAO encourages the establishment of safety data sharing Eurocontrol. The event will conclude with a presentation and networks. Information on data sharing and related tax- panel discussion on the safety benefits of NOSS. onomies is available at the organization’s website and can The event, to be conducted in English, is the second of its also be found at the JRC website. kind. The first symposium on TEM and NOSS in ATC was held ADREP information is available for accident prevention in Luxembourg in November 2005, with Eurocontrol as host. purposes and is provided on request to authorized officials in For details on NOSS, see “ICAO examining ways to monitor ICAO member States. ICAO receives some 130 ADREP safety during normal ATS operations,” Issue 3/2004, pp 14-16. queries from member States annually. The data is also used The venue for the Washington symposium, L’Enfant Plaza in various ICAO safety-related initiatives. ■ Hotel, can accommodate a maximum of 150 participants. Registration is on a first-come, first-served basis, and closes on 10 January 2007. For more information, contact Capt. Dan ICAO Council appointment ■ Maurino ([email protected], with a copy to [email protected]). Karin Kammann-Klippstein has been appointed Representative of Germany Experts to discuss performance on the Council of ICAO. Dr. Kammann- Klippstein’s appointment took effect framework for air nav system on 1 July 2006. A global symposium on the performance of the world’s air Dr. Kammann-Klippstein is a graduate navigation system will take place at ICAO headquarters from of the Universities of Hamburg and 26 to 30 March 2007. Government policy makers will join reg- Geneva, where she specialized in inter- ulators, air navigation services (ANS) providers, airport oper- national law and law of the European ators and airspace users in Montreal to discuss the perform- Communities. After serving as Coun- K. Kammann- ance of the air navigation system from the perspectives of Klippstein sellor for International Shipping Policy at safety, economics and management, operations, and tech- (Germany) the German Federal Ministry of Trans- nological developments. Some 500 participants are expect- portation, she was appointed Transpor- ed at the five-day event, which is seen as a follow-up to the tation Counsellor at the Permanent Mission of Germany to the 11th Air Navigation Conference held in 2003, during which a United Nations and other international organizations in Geneva. performance framework for an air navigation system based From 1992 to 1996, Dr. Kammann-Klippstein served as Deputy on the global air traffic management (ATM) operational con- Head of the Division for International Transportation Policy at the cept was outlined (see “11th Air Navigation Conference Federal Ministry of Transportation in Bonn. She was then appoint- adopts global framework for airspace management evolu- ed Transportation Counsellor at the German Embassy in tion,” Issue 8/2003, pg 24). Washington, D.C., a position she held until her appointment, in The symposium, which will heighten awareness of the need 2002, as Deputy Head of the Division for Coordination of Aviation to create a performance framework for the purpose of enhanc- and Shipping Policy at the Federal Ministry for Transportation, ing safety and efficiency in the air navigation system, is open Building and Urban Development in Berlin. ■

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AIR TRANSPORT BRIEFS Air Navigation Commission (ANC) on the work of the Committee on Aviation Environmental Protection (CAEP) and Global Symposium on Liberalization … An ICAO sympo- some of the key achievements anticipated for CAEP’s next sium on air transport liberalization held in Dubai, United Arab meeting in February 2007 (CAEP/7). Of particular note were Emirates on 18-19 September 2006 attracted over 250 partic- briefings on aviation emissions trading to better acquaint the ipants from 65 States and 11 international organizations. Led Council and ANC of key issues. These were presented by the by prominent speakers, the event provided an opportunity to Secretariat of the United Nations Framework Convention on share information, discuss issues and challenges, and explore Climate Change, the European Commission and CAEP’s ways to advance liberalization. The symposium was hosted by Emissions Trading Task Group. the Dubai Department of Civil Aviation. CNS/ATM business case analysis tool ... A computer Traffic forecasts for transpacific and intra-Asia/ application has been developed by the ICAO Air Transport Pacific … The ICAO Asia/Pacific Area Traffic Forecasting Bureau in support of the implementation of CNS/ATM sys- Group recently developed a set of passenger and aircraft tems. The CNS/ATM database and financial analysis comput- movement forecasts for transpacific and intra-Asia/Pacific er system (DFACS) model is an interactive, analytical tool that routes, as well as passenger forecasts for major city-pairs of enables air navigation services providers and airspace users to intra-Asia/Pacific and transpacific (the latter to the year build, evaluate and compare the economics of alternative 2010). The group also carried out analyses of flight informa- options or scenarios for the implementation of CNS/ATM sys- tion region (FIR) data for a sample week (1–7 July) for 2004- tems. A CD-ROM containing the computer application, along 06 for the Fukuoka, Bangkok and Hong Kong FIRs, including with a user’s manual and an illustrative example, has been the analysis of transpacific peak-hour aircraft movements. made available to ICAO regional offices. States may download These forecasts and analyses are included in the report of the the application and the documents from the ICAO-NET web- group’s October 2006 meeting, which will be available to site (Electronic publications/ ICAO documents). Contracting States on the ICAO-NET and on CD-ROMs to others in December. In addition, it will be posted on a dedi- Latest on trade-in-services matters … ICAO is closely cated ICAO aviation statistics website (www.icaodata.com). following work of the Council for Trade in Services (CTS) of the World Trade Organization (WTO), which has commenced Aviation emissions trading … ICAO Secretariat organized discussions on the second review of the Air Transport Annex a series of briefings recently to update the ICAO Council and of the General Agreement on Trade in Services (GATS), cov- ering developments in the civil aviation sector during the period 2000–05. The first review ending in 2000 did not result in any expansion of the annex, which covers three air trans- port services (aircraft repair and maintenance, computer reservation systems, and selling and marketing). Aviation inspirechange. authorities need to actively participate together with their trade counterparts in the discussions at CTS in order to exert AIS a leadership role by ICAO in the process of economic liberal- ization within a safe and secure air transport environment. AMHS Noise and emissions workshops … The third Workshop on Aviation Operational Measures for Fuel and Emissions Reduction was jointly organized by ICAO and Transport Canada ATN AIP on 20-21 September 2006 in Montreal to disseminate informa- AFTN tion on fuel and emissions reductions contained in ICAO’s Circular 303, Operational Opportunities to Minimize Fuel Use and Reduce Emissions, and to share practical experiences and Global provider of ATS messaging technology successful programmes that have contributed to emissions reductions in all aspects of the aviation industry. In addition, ICAO organized and held the third Regional Aircraft Noise 20 Years Experience Certification Workshop on 6-7 November in Bangkok, Thailand. 15+ Global Deployments Course on user charges … A training course on interna- tional policies and practices for the establishment of airport 50+ International Connections user charges was conducted in Zurich, Switzerland from 23- 27 October 2006. The course was the second in a series that 2 Customer Certifications for AMHS ICAO and the Airports Council International (ACI) are offering to airports (see Issue 4/2006, pg 16). The next ICAO/ACI workshop on airport user charges to be experience matters www.ubitech.com offered in the English language will be convened in Kuala Lumpur, Malaysia on 12-16 February 2007. French and Spanish language workshops will also be conducted in 2007. I

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Pandemic influenza guidelines regional network of experts who can provide advice to the now available at website aviation sector on preparedness planning, and in the event of an outbreak of a serious communicable disease. Guidelines that States can apply to reduce the risk of pan- If successful, the CAPSCA project will be extended to demic influenza being spread through air transport opera- Africa in 2007, and subsequently to other regions as well. ■ tions have been posted at the ICAO website (www.icao.int). Concurrently, a new provision has been adopted for ICAO ICAO and the Republic of Korea Annex 9, Facilitation, requiring that Contracting States estab- lish a national aviation plan for an outbreak of a communica- announce training programme ble disease posing a public health risk. The changes, which ICAO and the Republic of Korea have signed a memorandum of become applicable on 17 July 2007, revise the health infor- understanding on training programmes tailored for aviation per- mation part of the aircraft general declaration form. They also sonnel from developing countries. Under the agreement signed call for the introduction of a passenger locator card that pub- in September 2006, the Korea Civil Aviation Training Centre lic health officials can use to trace passengers who may have (KCATC) will provide selected participants with courses on the been infected by a serious communicable disease. global navigation satellite system (GNSS), nav aid maintenance, In a related development, the ICAO plan for the air trans- radar approach control and other technical subjects. To com- port sector’s response to the outbreak of a communicable mence in 2007, the training programme will be established and disease has been incorporated into a United Nations action administered jointly by the Korean Civil Aviation Safety Authority plan that spells out the role of various UN agencies and part- (KCASA), the Korea International Cooperation Agency (KOICA) ners in the event of a health emergency that requires a coor- and the ICAO Technical Cooperation Bureau. dinated global response. The initial programme is being offered on an annual basis The guidelines which are now available from ICAO are an for a three-year period, at which point it may be extended. important step in preparedness planning. Avian influenza cur- The training initiative will accommodate about 39 participants rently poses a substantial risk to the global population per year initially, and is being funded by the Ministry of because it is likely that at some unpredictable point in the Construction and Transportation of the Republic of Korea future a strain of influenza will emerge that transmits easily (MOCT) and the KOICA. between humans. If this were to occur, the World Health The annual curriculum will reflect the changing needs of Organization (WHO) may call on the aviation community to developing countries and is intended to promote the develop- implement measures to limit the spread of disease. ment and safety of international civil aviation. To be conduct- Moreover, aviation would undoubtedly be detrimentally ed in English, the programme will be available to specific affected by decreased traffic to areas where there is a per- countries identified by ICAO and the MOCT, with final selection ceived increased risk of disease. For both reasons it is there- of the students to be determined by the Republic of Korea. fore necessary to plan for such an event. The Korea Civil Aviation Training Centre, also known as the The guidelines were developed over a period of months in Korea Civil Aviation Academy (www.catc.airport.co.kr/), was cooperation with WHO, the Centers for Disease Control and established in 1984 with financial and technical assistance from Prevention (CDC), Airports Council International (ACI), the United Nations Development Programme (UNDP) and ICAO, International Air Transport Association (IATA), and other and with the objective of meeting the developmental needs of organizations with appropriate expertise. The international civil aviation in the Republic of Korea. KCATC has played a major effort was coordinated by ICAO, which gained experience in role in the enhancement of technical expertise in Korean civil avi- developing related guidelines during the severe acute respi- ation, and has offered an international fellowship programme ratory syndrome (SARS) outbreak in 2003. since 2001. During the 2001-06 period, the centre provided fel- Generic in nature, the ICAO guidelines are based on the lowship training to 173 participants from 49 countries. WHO International Health Regulations published in 2005, and can be applied to many communicable diseases, not only influenza. They will continue to be modified over time as more information is gained on preparedness planning and on the behaviour of relevant infectious agents. In addition to guidelines that are directed towards States, more detailed guidance has been developed specifically for use by airport operators and airlines. This information is available from ACI and IATA respectively. ICAO has also been active in promoting a coordinated response to any health crisis. The Asia/Pacific region is the first to be involved in an ICAO project that aims to harmonize preparedness plans across the globe, known as the Cooperative Arrangement for Preventing the Spread of Communicable Diseases through Air Travel (CAPSCA). The An instructor with students at the Korea Civil Aviation Training purpose of this project is to ensure that international airports Centre. Beginning in 2007 the centre will provide training for par- have a preparedness plan in place that is aligned with ICAO ticipants from developing countries under an MOU signed by guidelines. Another important aim is the development of a ICAO and the Republic of Korea. ■

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Like any other aspect of business, safety management sys- ATM safety tems demand that a plan be drawn up. This plan attempts to continued from page 25 ensure that all safety issues are listed and assigned priority, and the region that are not members of ECAC to review and that action is initiated with sufficient allocations of people, time, strengthen their ATM safety frameworks. money, tools and the processes needed to do the job properly. You have individual needs. We have the individuals. The introduction of the Single European Sky presents fresh Organizing tasks usually entails the striking of a safety team, safety challenges for European authorities, and with this in mind with a manager responsible for the achievement of the plan’s Eurocontrol recently launched a new safety initiative known as the goals. The team should be made up of personnel with the need- European Safety Programme for ATM. The proactive programme ed skills set. This may involve a significant degree of coordina- looks forward and identifies areas that need improvement to meet tion between organizational units. the challenges presented by the ever-increasing level of traffic and Controls are put in place, and the environment monitored for SES implementation. In particular, the reporting of ATM occur- change. This involves benchmarking safety performance or rences and the sharing of lessons learned need to be improved. comparing this performance with a departure point, measuring Over the past four years European ATM providers have the results and making corrections if the desired results are not strengthened and improved their safety management systems. achieved. Finally, management system thinking demands con- There is now a much greater awareness among ATM providers tinuous improvement. It demands continuous learning and of what is required in respect of safety frameworks, and there searching for better ways of doing things and institutionalizing is greater cooperation between the various organizations and those processes that prove their worth. associations active in Europe. The next few years will see tar- In summary, a safety management system consists of compo- geted workshops on different aspects of SMS that will be held nents and elements that provide for a comprehensive approach across Europe and Northern Africa. to safety, an effective organization to achieve safety, and the sys- An ATM safety management system provides a structured tems needed to provide for safety oversight. basis on which to develop, organize and manage all of the various Safety philosophy and policies. A comprehensive corporate elements that are required to ensure that air traffic is managed in approach to safety speaks to the need for aviation organizations to the safest way. Considering that risk must be managed daily, with establish a safety philosophy and appropriate policies. This calls for steadily increasing traffic and the advent of new technology and organizations to establish their fundamental approach to managing new procedures, it is incumbent on everyone involved to maintain safety in terms of leadership and direction, planning, controlling, the highest level of safety possible. Safety cannot be left to chance, and measuring performance, as well as related functions that per- and together we must ensure that accident rates are reduced to meate the entire organization. compensate for the expected future growth in air travel. ■ An “effective organization to achieve safety” speaks to such things as roles, responsibilities, accountabilities, structure and means of achieving coordination among organizational units. SMS fundamentals “Systems to achieve safety” speaks to the establishment of the continued from page 17 various means for accomplishing this. Such systems must be statutory and internally promulgated safety rules, and second- introduced in order to achieve compliance with statutory or ly, they focus on prevention and/or reduction of harm arising internally promulgated rules; identify the hazards and risks out of a firm’s decisions and operations. associated with different operations; assess and mitigate the Management strategies attempt to systematize management known risks; report safety deficiencies, accidents and inci- functions and processes to enhance or optimize organizational dents; contain accidents and prepare for likely emergencies; performance. With respect to a business strategy, as with any investigate accidents and incidents, and disseminate the les- management system, a safety management system must pro- sons learned and correct system deficiencies — all the while vide opportunities to create and capture shareholder value. documenting the processes, decisions and actions throughout. This approach recognizes that a firm is in the business of mak- Transport Canada believes that a safety management system ing money for its owners. will enable aviation organizations to better manage risk and In order to achieve the goals of ensuring compliance and pre- contribute to their bottom line. To quote James Reason, SMS venting or reducing harm arising out of a company’s decisions helps aviation firms “navigate the safety space” between bank- and actions, safety strategies incorporate a number of elements, ruptcy and catastrophe by providing the means to better bal- specifically those concerned with compliance, risk manage- ance investments in protection and production. ment, prevention, containment and remedial action. Managers face myriad challenges in their attempt to make Management strategies refer to the system by which man- money. But at their most fundamental level, safety management agers perform their functions, in particular their efforts to lead, systems can help a company reconcile the social demand for plan, organize, control and achieve improvements. The goal of enhanced safety with the shareholder’s expectation for better these management strategies is to enhance organizational per- financial returns and, perhaps, keep the regulator happy at the formance in terms of effectiveness, efficiency and economy. same time. ■ To be truly effective, efficient and economic, a safety man- agement system requires leadership. A company’s executives must possess the commitment to pursue safety as a core value Safety information www.shell.com/aviation of their organization. They must be cognizant of the safety risks continued from page 30 faced by their firm and competent enough to put in place the a requirement for transport category aircraft to be equipped measures that can bring about effective and lasting results. with a take-off performance monitoring system that would pro-

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You have individual needs. We have the individuals.

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ICAO Council appointment • Write down complex taxi instructions. When unsure of the taxi route, request progressive taxi instructions from Air Traffic Ambassador Gil-sou Shin has been Control (ATC). appointed Representative of the • If the flight has more than one crew member, it is important that Republic of Korea on the Council of both fully understand taxi clearances and runway assignments. ICAO. His tenure commenced on 26 • During taxi operations, the pilots’ maximum attention should September 2006. be placed on maintaining situational awareness. The pilot taxiing Ambassador Shin is a graduate of should have his attention focused outside the aircraft at all times the Seoul National University, where while the other pilot should monitor the taxi progress by refer- he majored in economics. He joined ence to the airport diagram and give guidance to the taxiing pilot. his country’s Ministry of Foreign Affairs • Apply CRM procedures to identify and resolve conflicting per- in 1978, and served in a number of G. Shin ceptions of ATC instructions; confirm, by using the challenge- (Republic of Korea) positions of increasing responsibility and-response technique, proper execution of ATC instructions; both at home, in different divisions of and confirm, using this same technique, that the aircraft is actu- the Ministry of Foreign Affairs and Trade (MOFAT), as well as ally positioned on the assigned runway by reference to the abroad, in embassies of the Republic of Korea in Africa, Asia heading indicator. and Europe. His most recent assignments have included those • Use all available resources to ensure the aircraft is positioned of Counsellor at the Permanent Mission of the Republic of on the proper runway. One technique for aeroplanes that are Korea to the United Nations Secretariat and International equipped with a flight management system (FMS) is to verbally Organization in Geneva; the Deputy Director-General for announce that the proper runway and departure procedure are Commerce and Trade Policy at the MOFAT; and the Minister of selected in the FMS and that the aircraft heading agrees with the Embassy of the Republic of Korea in the Philippines. the assigned runway for take-off. In addition to his recent appointment as Representative on The U.S. NTSB is continuing its investigation of the accident, the ICAO Council, Ambassador Shin is currently serving as which occurred when the aircraft attempted to take-off from an ■ Consul General of the Republic of Korea in Montreal. inoperative 3,500-foot runway instead of the 7,000-foot runway that it had been assigned by ATC. ■ vide flight crews with an accurate and timely indication of inad- equate take-off performance.” Comair Flight 5191. The U.S. Federal Aviation Admin- Business Plan commitment istration (FAA) has issued a safety alert in the wake of the 27 continued from page 7 August 2006 crash of a Comair Bombardier CRJ100 at the greatest challenge is that of putting these programmes into Lexington, Kentucky Blue Grass Airport (KLEX). The safety practice. While both the business plan and SMS implementation alert for operators (SAFO), No. 06013 dated 1 September 2006, are evolved forms of past ideas, proper execution demands that is available at the FAA’s website (www.faa.gov/other_visit/avia they be seen as new concepts. While seemingly a subtle distinc- tion_industry/airline_operators/airline_safety/safo). tion, this approach prepares one mentally to go beyond simple The recent accident, in which a commuter jet took off from the adaptation of past practices and behaviour to formulate new strate- wrong runway, “brings into focus the importance of maintaining gies based on the best practices and operational experience. situation awareness and adherence to CRM procedures,” the Over the next decade, the ICAO business plan and safety FAA stated. “It is important to note than many airports are management concept will undergo a series of trials and itera- involved in construction activities that result in changing envi- tions. The ICAO Assembly will streamline the organization’s ronments. This heightens the importance of pilot vigilance. strategies, and the effects of this enhanced institutional effi- “There are many other factors that can distract a pilot and ciency will be obvious to all from the organization’s updated cause the loss of situational awareness. Even subtle distractions business plan and associated performance indicators. At the could demand a share of the pilot’s workload, such as dealing same time, the governing boards of operators of countless avi- with company procedures, passengers, running late and even ation systems worldwide will periodically adjust their safety personal issues,” the SAFO stated. indicators and targets to meet their acceptable levels of safety. “It is imperative that flight crews maintain the highest levels And while the SMS and ICAO business plan will ultimately of airmanship discipline and crew resource management. This grow outdated — like all other forms of management that have is especially significant during the critical phases of flight, take- preceded them — they can be expected in the meantime to pro- off and landing.” vide an effective response to the safety concerns that may The SAFO reminded flight crews of the following existing emerge over the coming decades. ■ guidance: • As part of pre-flight planning, review airport layouts and know airport signage. SMS implementation • Review NOTAMs for information on runway and taxiway clo- continued from page 8 sures and construction areas. States in implementing the harmonized provisions will be deliv- • During taxi operations, have a current airport diagram readi- ered in each of ICAO’s seven regional offices. ly available for reference and check the assigned taxi route While a great deal is being done to implement SMS as a tool against the diagram, paying special attention to any unique or for managing safety, it is important to bear in mind that this complex intersections. implementation does not obviate the need to comply with the

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specifications and regulations in force. relevant sources of safety information. Importance of training. Training that can assist States with Conclusion. Under the prevailing situation in international the global implementation of SMS is very important, and con- civil aviation, it is becoming increasingly difficult to dissociate sequently ICAO recently developed such a course. During safety from efficiency. Aviation organizations, no matter their 2006, the organization conducted three courses for different core business activity or geographical location, must not only be regions, and four more courses will be delivered next year. safe but efficient. Even organizations that are not directly The goals of the ICAO SMS training course, which builds involved in a measurable production activity, such as civil aviation upon the harmonized safety management provisions and administrations, are under pressure to discharge their mandate Document 9859, are to expand the knowledge of the safety in the face of ever-diminishing resources. Hence, the value and management concepts and related SARPs contained in ICAO importance of SMS. Annexes 6, 11 and 14, as well as guidance material. Another SMS presents the international aviation community with a prin- goal is to develop States’ capacity to certify and oversee the cipled, data-driven approach to determining priorities and allocat- implementation of key components of a basic SMS in compli- ing the resources required to address safety concerns that hold ance with ICAO SARPs and national regulations. the greatest risk potential, and towards activities likely to pro- The target audience for the courses includes civil aviation duce the biggest return on resources invested. SMS also pro- administration officials who are responsible for the implemen- vides the means to address safety systemically and proactively tation of safety programmes and the oversight and/or imple- through hazard analysis and risk assessment and mitigation. In mentation of safety management systems in the areas of aircraft this manner, SMS presents the international aviation community operations, air traffic services and aerodromes. with clear means to achieve more, safety-wise, with less. The ICAO SMS training course, delivered in five days, com- ICAO has worked determinedly toward harmonizing SMS prises 10 modules and six case studies to allow participants to concepts, guidance material and SARPs, in addition to develop- apply their newly acquired knowledge in a practical setting. ing a comprehensive training course, and is now preparing to Topics covered include safety basics, fundamentals of safety deliver this course as far and wide as possible. management, hazard identification and risk management, The full potential of SMS will be realized when the concept is ICAO SMS regulation, and the development, implementation adopted on a global basis, by all Contracting States and, through and operation of an SMS. The course includes daily progress States, by as many aviation organizations as possible. In order tests and a final examination. for this worldwide implementation to take place, States need to To provide sufficient SMS training opportunities in the years be fully aware and informed about the SMS concept and the ahead, ICAO plans to develop training for course instructors as means and tools for its implementation. ■ this will allow States to become self-sufficient both in SMS imple- mentation and in imparting SMS training. Moreover, as States develop these internal resources, they will be in a position to SMS standards assist other States with their implementation of safety manage- continued from page 12 ment systems, thus achieving the synergistic partnership neces- Another initiative is to better integrate the existing suite of advi- sary for the global execution of safety management systems. sory circulars into a comprehensive safety and quality manage- SMS training is available from ICAO on request from individ- ment system concept for the aviation industry. Part of this effort ual States or groups of States. The course, designed for a max- will include the development of more sophisticated operational imum of 30 participants, includes study materials provided to risk analysis techniques including the effects of operational States in electronic format. At present, it is conducted either in changes on system safety. Particular targets for these efforts will English or Spanish, but it is expected that availability will be include existing advisory circulars and other documentation for an expanded to other languages. internal evaluation programme, continuing analysis and surveil- Once the training has been completed and instructors have lance systems and the Voluntary Disclosure Reporting been endorsed, States may use the ICAO training course and Programme (VDRP). Along these same lines, future study will its materials without restrictions. From time to time, the course also explore safety management in other fields of aviation, as well material may be updated by ICAO, in which case States will be as industry-developed management programmes in common use. provided with new material in electronic form. States may The FAA further plans to infuse the concepts of SMS into the obtain further details on the SMS training programme at agency’s oversight systems. The four pillars will be applied to the ICAO’s website (www.icao.int/anb/safetymanagement). processes of producing regulations, standards and policies such ICAO’s initial effort in assisting States with implementing that these will be viewed as system risk controls. Future rulemak- SMS will continue for another year, at which point further activi- ing will be based more on risk analysis so that the FAA can be sure ties may be undertaken. These could involve identifying a means that necessary controls are in place, and that obsolete regulations for further pursuing safety management activities, including that no longer are needed to control risk can be eliminated. related training, on a regional basis. It could also entail the devel- In a similar manner, safety assurance of the overall aviation opment of guidance material and provision of assistance for the system will be based on analysis of data coming from FAA field establishment of safety data collection and analysis systems in elements as well as directly from aviation service providers. States. Future work might involve efforts to improve safety data Information sharing will receive much greater emphasis than analysis capabilities in States, and the linking of regional systems before as a fundamental part of the FAA risk management and for the exchange of safety information and analysis. Also envi- safety assurance strategy. In this manner, the total govern- sioned is the development of guidance material and provision of ment/industry safety management strategy can be made more assistance for the enactment of national legislation to protect all effective and efficient. ■

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Single European Sky Protection of safety data continued from page 23 continued from page 28 them establish a certification regime compliant with Single of justice, and that its release outweighs the adverse domestic IN THE European Sky principles and place them in a position to veri- and international impact such release may have on the future fy and show compliance with the common certification availability of safety information. SPOTLIGHT... requirements. In addressing the subject of public disclosure, the ICAO As part of the move towards SES, ESARRs are now being pro- guidelines propose — subject to the principles of protection and gressively transposed into European Communities law. They exception outlined above — that the onus to justify the release are appearing as EC regulations, which have direct applicabili- of information should be on those seeking disclosure. Formal ty in EU member States, and as EC directives, which need to be criteria for disclosure should be established and should require transposed at the national level. that several conditions be met. Information may be released pro- Ensuring that safety management systems are embedded vided its disclosure is necessary to correct conditions that com- throughout the Single European Sky is a fundamental prerequi- promise safety or to change policies and regulations, so long as site to the safe transition to new procedures. ESARR require- the disclosure does not also inhibit the availability of informa- ments for safety management systems have therefore been tion in the future. Such disclosures should be made in a de-iden- included as essential criteria to be met by ANS providers before tified, summarized or aggregate form. Moreover, disclosure of they can be certified. I relevant personal information included in the safety information needs to comply with applicable privacy laws. The legal guidelines also discuss the responsibility of the Representative of Australia custodian of safety information, proposing that each SDCPS Simon Clegg has served as the Rep- should have a designated guardian. This protector is responsi- resentative of Australia on the Council ble for applying all possible safeguards to the information of ICAO since mid-2003. Prior to unless consent for disclosure has been granted by the origina- assuming his current post, Mr. Clegg tor, or the custodian is satisfied that its release is justified for held a number of positions in his exceptional reasons. country’s Department of Transport Lastly, the guidelines address the protection of recorded and Regional Services. information, which ICAO recommends be treated as privileged Mr. Clegg played a leading role in protected information (i.e. information deserving enhanced most of the major reforms to protection) since ambient workplace recordings required by Australian aviation in the past legislation, such as cockpit voice recorders (CVRs), may be S. Clegg perceived as an invasion of privacy. What’s more, ICAO propos- (Australia) decade, including the privatization of major airports and the establishment es that national laws and regulations provide specific measures of two specialized agencies, Airservices Australia and the of protection to such recordings, upholding their confidentiali- Civil Aviation Safety Authority of Australia. Mr. Clegg was ty and spelling out rules for public access. Specific measures of leader of the government task force set up to deal with the protection for workplace recordings could include orders deny- effects of the terrorist attacks of 11 September 2001 on the ing public disclosure. I aviation insurance market. During 2001-02, he served as Chairman of the ICAO Special Group on War Risk Insurance. Mr. Clegg’s most recent position in Australia was that of Airport safety Director, Aviation and Maritime Legal, a role in which he continued from page 21 advised widely on a range of legal issues associated with on current resources. Australia’s international and domestic aviation policy. In this • Keep it simple. If the safety management system is to be capacity, he worked closely with aviation safety investigation “saleable” to all staff, it is important that it remain simple and teams and spearheaded development of comprehensive new understandable. Gaining trust in the system is another impor- national legislative regimes for both aviation and maritime tant facet. Both staff and management must embrace owner- security. In addition, Mr. Clegg chaired several government ship of the system. working groups, among them the GNSS Legal Issues • Use and enhance existing practices. Each organization is Working Group and the Joint Australia-New Zealand Working bound to have current practices that may be incorporated into Group. The latter group developed the legislation for mutual the safety management system. For example, a procedure for recognition of aviation certificates, a necessary step in imple- investigation of incidents already exists in many organizations. menting arrangements for a single aviation market for the two Adapting existing practices as much as possible is advanta- countries. geous because this can support a trouble-free implementation. Mr. Clegg holds degrees in economics, commerce and law • Share the responsibility. The safety manager is the individual from the University of Adelaide, and is a barrister of the High responsible for developing and implementing a safety manage- Court of Australia. He has been a visiting lecturer at the ment system. The safety manager should organizationally serve Australian National University, where he conducted a post- in a support role to the aerodrome manager. It is important to graduate course in international air law for several years. emphasize, however, that this individual is not alone in being Before joining the Australian Government, he worked for the responsible for safety at the aerodrome. Rather, safety must be chartered accounting firm, Ernst & Young. I the responsibility of the entire airport management. I

40 ICAO JOURNAL 38701.P41 12/7/06 9:40 PM Page 41

IN THE SPOTLIGHT...

FOCUS ON WAFS The third meeting of the World Area Forecast System Operations Group (WAFSOPSG) took place at the ICAO European and North Atlantic Regional 14-BIS MODEL Office in Paris in late September 2006. In addition to operational issues, Brazil presented ICAO with a miniature replica of the aircraft piloted the group addressed development of the WAFS and endorsed introduction th by aviation pioneer Alberto Santos-Dumont on the 100 anniversary of of trial grid-point forecasts for icing, turbulence and convective clouds that his first flight in October 1906. The replica serves as a reminder to the are to be evaluated before their anticipated operational implementation international community of how one man’s gift to the world still inspires in 2010. Given the slower-than-expected operational implementation of us today, Brig. Sérgio Luiz de Oliveira Freitas, of the Brazilian Embassy the BUFR-coded significant weather forecasts by States, the group agreed in Washington, D.C., stated during the presentation on 25 October. that this information would continue to be made available in PNG chart Shown on the occasion are (l-r) Brig. Freitas; ICAO Council President form, as a back-up, until 2010. The third meeting of WAFSOPSG was Roberto Kobeh González; ICAO Secretary General Taïeb Chérif; and Pedro attended by 28 experts from 14 States and four international Bittencourt de Almeida, the Representative of Brazil on the Council organizations, representing all ICAO regions. of ICAO.

DEPOSIT BY COLOMBIA Colombia deposited its instrument of ratification of the Convention on the International Recognition of Rights in Aircraft, signed at Geneva in HUNGARIAN SCULPTURE June 1948, during a brief ceremony at ICAO headquarters on 8 September Hungary recently presented ICAO with a bronze statue entitled 2006. Shown on the occasion are (seated, l-r): Gloria Cecilia Rodriguez “Generations” that was created by Hungarian sculptor Robert Varon, Ministry of Foreign Affairs, Colombia; Denys Wibaux, Director Csikszentmihalyi. The gift commemorates ICAO’s 60th anniversary. of ICAO Legal Bureau; Julio Enrique Ortiz Cuenca, Representative of Shown following the presentation at ICAO headquarters in June 2006 Colombia on the Council of ICAO; and Maria Cecilia Salazar Cruz, Civil are (l-r): Dr. Attilio Sipos, Representative of Hungary on the Council Aviation Administration, Colombia. Standing (l-r): Luis Miguel Garcia of ICAO; Roberto Kobeh González, then ICAO Council President-elect; Lancheros, Delegation of Colombia to ICAO; Cesar Augusto Bejarano Dr. Assad Kotaite, then ICAO Council President; Dr. Laszlo Kiss, Ramon, Delegation of Colombia to ICAO; and Walter Amaro, of the Director General of Civil Aviation, Hungary; and ICAO Secretary ICAO Technical Cooperation Bureau. General Dr. Taïeb Chérif. 38701.P42 12/7/06 9:42 PM Page 42

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