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1.0 Safety Management Plan

1.1 Purpose, Scope and Applicability This Safety Management System (SMS-P) Manual has been developed to describe the requirements for Agni Air maintenance organizations Safety Management System. This safety management system is denoted as SMS-P, to indicate that it applies to a producer or provider of services and shall be part of Agni Air SMS Manual. Introduces the concept of a safety management system (SMS) to aviation maintenance organization. A safety management system applies quality management concepts to human organizational aspects of production and support processes to achieve safety goals. The Maintenance Procedure Manual describes the companys organizational structure, scope of maintenance, responsibility, general company rules & procedures used in the maintenance of the companys aircraft and associated equipment. While the CAA NEPAL encourages each aviation maintenance organization to develop and implement an SMS, these systems in no way substitute for regulatory compliance of other certificate requirements, where applicable. This manual is intended to address aviation safety related operational and support processes and activities rather than occupational safety, environmental protection, or customer service quality.

1.2 Safety Policy All levels of management are accountable for safety performance and are committed to providing safe, healthy, secure work conditions and attitudes with the objective of having an accident-free workplace. Making safety excellence part of all activities strengthens the organization. The organizations leader is committed to: Ongoing pursuit of an accident-free workplace, including no harm to people, no damage to equipment, the environment or property. A culture of open reporting of all safety hazards in which management will not initiate disciplinary action against any personnel who, in good faith, discloses a hazard or safety occurrence due to unintentional conduct. Regular and ongoing support for safety training and awareness programs. Regular audits of safety policies, procedures and practices are conducted. Monitoring industry activity to ensure best safety practices are incorporated in to the organization. Providing and promoting the necessary resources to support this policy. Requiring all employees to be responsible for maintaining a safe work environment through adherence to approved policies, procedures and training.

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Requiring all employees to familiarize themselves and comply with safety policies and procedures. 1.3 Safety Principles Always operate in the safest manner practicable. Never take unnecessary risks. Familiarity and prolonged exposure without a mishap leads to a loss of appreciation of risk. Safe does not mean risk free. Everyone is responsible for the identification and management of risk. A culture of open reporting of all safety hazards in which management will not initiate disciplinary action against any personnel, who in good faith, due to unintentional conduct, disclose a hazard or safety incident. 1.4 Organizational Structure and Safety Responsibilities The organizations structure is described in the Maintenance Procedure Manual. Responsibilities of organizations top management is described below. CEO is responsible for the following safety accountabilities: manner practicable. -term safety objectives, including the establishment of safety policies and practices. and maintain safe work practices. policies and procedures oversight and safety program rigor. Chief Safety Officer is responsible for: ning and reporting all safety related data, including the minutes of safety meetings. risk management. ng and presenting audit reports and remedial actions. The chief of pilot is responsible for: and comply with applicable regulatory requirements, standards and the organizations safety policies and procedures. achieve safe flight operations. and supervising aircrews. organizational goals, objectives and regulatory requirements.

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personnel as they impact

flight safety. The chief of maintenance is responsible for: understand applicable regulatory requirements, standards, and organization safety policies and procedures. achieve safe maintenance operations. and supervising maintenance personnel. personnel performance compliance with organizational goals, objectives and regulatory requirements. personnel as they impact flight safety. 1.5 Compliance with Standards All personnel have the duty to comply with approved standards including organization policy and procedures, aircraft manufacturers operating procedures, and limitations, and government regulations. Research shows that once you start deviating from the rules, you are almost twice as likely to commit an error with serious consequences. Breaking the rules usually does not result in an accident; however, it always results in greater risk for the operation, and the organization supports the principle of, NEVER take unnecessary risks. 1.6 Intentional non-compliance with standards Behavior is a function of consequences. Management is committed to identifying deviations from standards and taking immediate corrective action. Corrective action can include counseling, training, discipline, grounding or removal. Corrective action must be consistent and fair. Organization management makes a clear distinction between honest mistakes and intentional non-compliance with standards. Honest mistakes occur, and they are addressed through counseling and training. Research has shown that most accidents involve some form of flawed decision-making. This most often involves non-compliance with known standards. Non-compliance rarely results in an accident; however, it always results in greater risk for the operation. 1.7 Rewarding People This organization is committed to the principle that people are rewarded for normal, positive performance of their duties that comply with organization standards.

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Personnel will not be rewarded for accomplishing the mission by breaking the rules. Reinforced bad behavior breeds continued bad behavior. This is unacceptable. 1.8 Safety Promotion Safety is promoted as a core value within the organization. Procedures, practices and allocation of resources and training clearly demonstrate the organizations commitment to safety. The following methods are used to promote safety: Post the Safety Policy in prominent locations around the base of operations. Start meetings with a comment or review about safety issues. Have a safety bulletin board. Have an employee safety feedback process. 1.9 Documentation and records management Technical libraries shall be kept current (for such things as technical publication, airworthiness directives and service bulletins). Maintenance defects and work completed shall be recorded in detail. Operational data shall be monitored for reliability analysis. Corporate safety policies, objectives and goals shall be formally documented and distributed. Records on certifying staff on training, qualification and currency, etc. shall be kept. Information on Inspection status, component history, life, etc. shall be kept. 1.10 Hazard Identification & Risk Management The systematic identification and control of all major hazards is foundational. The success of the organization depends on the effectiveness of the Hazard Management Program. Hazards are identified through employee reporting, safety meetings, audits and inspections. When a major change in operations, equipment or services is anticipated, the management of change process includes hazard identification and risk management processes. Risk management is the identification and control of risk. It is the responsibility of every member of the organization. The first goal of risk management is to avoid the hazard. The organization establishes sufficient independent and effective barriers, controls and recovery measures to manage the risk posed by hazards to a level as low as practicable. These barriers, controls and recovery measures can be equipment, work processes, standard operating procedures, training or other similar means to prevent the release of hazards and limit their consequences should they be released. The organization ensures that all individuals responsible for safety critical barriers, controls, and recovery measures are aware of their responsibilities and competent to carry
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them out. The organization establishes who is doing what to manage key risks and ensures that these people and the things they do are up to the task. 1.11 Occurrence & Hazard Reporting All occurrences and hazards identified by an employee in the maintenance organization will be reported to the safety officer using the Event Reporting Form. Occurrence - Definition An occurrence is defined as any unplanned safety related event. This would include accidents and incidents that could impact the safety of guests, passengers, organization personnel, equipment, property or the environment. Hazard Definition A hazard is defined as something that has the potential to cause harm to people and/or the loss of or damage to equipment, property or the environment. Occurrences Personnel who report are treated fairly and justly, without punitive action from management except in the case of known reckless disregard for regulations and standards, or repeated substandard performance. The Just Culture process is used when deciding if disciplinary action is appropriate. 1.12 Emergency Preparedness & Response The detail of the crisis management and emergency response plan is contained in the Company SMS Manual.

2.0 SMS in Aircraft Maintenance

2.1. Maintenance Safety 2.1.1. Maintenance Safety General Maintenance and inspection errors are cited as a factor in a number of accidents and serious incidents worldwide each year. The safety of flight is dependent on the airworthiness of the aircraft. Safety management in the areas of maintenance, inspection, repair and overhaul are therefore vital to flight safety. Maintenance organizations need to follow the same disciplined approach to safety management as is required for flight operations. Conditions for maintenance-related failures may be set in place long before an eventual failure. For example, an undetected fatigue crack may take years to progress to the point of failure.

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Risk potential may be created by the conditions under which maintenance is often conducted, including such variables as organizational issues, work site conditions and human performance issues pertinent to aircraft maintenance. The term safety in an aircraft maintenance context is often considered to have two connotations. One is an emphasis on industrial safety and hygiene for the protection of Maintenance personnel, facilities and equipment. The second is the process for ensuring that Maintenance personnel provide airworthy aircraft for flight operations. Although the two may be inextricably linked, this chapter concentrates on the latter, with little reference to Occupational Safety and Health (OSH) issues.

2.1.2. Maintenance Working Conditions Agni Air management shall pay attention to the following typical issues impacting on the working conditions under which aircraft maintenance is carried out to foster safe maintenance environment and safety culture: Organizational issues: Time pressures to sustain on-time departures and around-the-clock operations. Ageing aircraft requiring intensive inspections for fatigue, corrosion, overall condition, etc. New technologies requiring new tools, new work procedures, costly retraining, etc. fix-it focuses to stay on schedule (e.g. replacing broken parts without determination as to why they failed perhaps due to poor design or incorrect assembly). Airline expansions and mergers (e.g. combining maintenance departments with different work practices and safety cultures). Outsourcing of services to subcontractors (e.g. for heavy maintenance and overhaul). Unwitting introduction of (lower cost, substandard) bogus parts, etc.; and licensing of Maintenance personnel for different aircraft, aircraft generations, types and manufacturers. Work site conditions: Aircraft designs that are not user-friendly from a maintenance perspective (for example, cramped access to components and inappropriate height off the ground). Control of aircraft configurations (which are continually subject to modifications) versus standardization of maintenance tasks and procedures. Availability (and accessibility) of spares, tools, documentation, etc. Requirements for having ready access to voluminous technical information, and the need for maintaining detailed work records. Variable environmental factors (for example, conditions on the ramp versus in the technical workshop versus on the hangar floor). Unique operating conditions created by concurrent activities and inclement weather on the ramp.

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Shortcomings in the provision of timely, accurate, understandable discrepancy reports by flight crews, etc.

Human Factors in maintenance: Organizational and working conditions (as described above). Environmental factors (e.g. temperature, lighting and noise). Individual factors (e.g. workload, physical demands and maintenance). Scheduling (e.g. shift work, night work and overtime) versus adequacy of rest periods. Appropriateness of SOPs (e.g. correctness, understandability and usability). Quality of supervision. Proper use of job cards, etc. Adequacy of formal training, on-the-job training (OJT), recurrent training and Human Factors training. Adequacy of handovers at shift changes and record keeping. Boredom and cultural factors (e.g. AMEs professionalism and openness to report errors and hazards). 2.2. Quality Policy Top management will ensure that the organizations quality policy is consistent with the SMS. 2.3. Safety Management in Maintenance All levels of management are accountable for safety performance and are committed to providing safe, healthy, secure work conditions and attitudes with the objective of having an accident-free workplace. Making safety excellence part of all activities strengthens the organization. Resource Allocation To protect against losses due to an accident, resources shall be allocated for: Personnel with expertise to design and implement the maintenance safety system. Training in safety management for all staff. Information management systems to store safety data, and expertise to analyze the data. Safety Culture:

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An organizations culture consists of its values, beliefs, legends, rituals, mission goals, performance measures, and sense of responsibility to its employees, customers, and the community. A poor safety culture in a maintenance organization can lead to unsafe work practices not being corrected; possibly creating latent unsafe conditions that may not cause a problem for years. Agni Air Management is committed to foster a positive safety culture by honest implementation of SMS. 2.4 Principal tools for safety management in maintenance Effective operation of an SMS for maintenance builds upon risk-based decision-making, a concept that has long been integral to maintenance practices. For example, maintenance cycles are built upon probabilities that systems and components would not fail for the period of the cycle. Components are often replaced because they are time expired, even though they may remain functionally serviceable. Based on knowledge and experience, risks of unexpected failure are reduced to acceptable levels. Some of the principal tools for operating an SMS for the maintenance function that Agni Air shall follow include: Clearly defined and enforced Maintenance Exposition Manual. Risk-based resource allocations. Hazard and incident reporting systems. Flight data analysis programs. Reliability Analysis. Competent investigation of maintenance-related occurrences. Training in safety management. Communication and feedback systems (including information exchange and safety promotion). 2.5 Safety oversight and program evaluation As with any system, feedback is required to ensure that the individual elements of the maintenance SMS are functioning as intended. Continuing high standards of safety in a maintenance organization imply regular monitoring and surveillance of all maintenance activities. This is especially so at the interfaces between workers (such as between maintenance personnel and flight crews, between personnel of different trades, or between staff on changing work shifts) to avoid problems falling through the cracks. Change is inevitable in the aviation industry, and the maintenance area is no exception. The Director of Engineering may require that a safety assessment be carried out in respect of any significant changes in the maintenance organization. Circumstances that might warrant a safety assessment include a corporate merger, and introduction of a new
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fleet, equipment, systems or facilities. Consequently, the need for any adjustments can be identified and corrected. The maintenance SMS shall be regularly evaluated to ensure that expected results are being achieved. The areas to be evaluated are: To what extent has management succeeded in establishing a positive safety culture? What are the trends in hazard and incident reporting (by technical trade, by aircraft fleet, etc.)? Are hazards being identified and resolved? Have adequate resources been provided for the maintenance SMS?

3.0 Managing Procedural Deviations in Maintenance

3.1 General The maintenance system includes not only the Maintenance personnel on the shop floor but also all the other technicians, engineers, planners, managers, stores keepers and other persons that contribute to the maintenance process. In such a broad system, procedural deviations and errors in maintenance are inevitable and pervasive. Accidents and incidents attributable to maintenance are more likely to be caused by the actions of humans than by mechanical failure. Often, they involve a deviation from established procedures and practices. Even mechanical failures may reflect errors in observing (or reporting) minor defects before they progress to the point of failure. Maintenance errors are often facilitated by factors beyond the control of the maintenance staff. Safe maintenance organizations foster the conscientious reporting of maintenance errors, especially those that jeopardize airworthiness, so that effective action can be taken. This requires a culture in which staff feels comfortable reporting errors to their supervisor once the errors are recognized. Agni Air shall follow Maintenance Error Decision Aid (MEDA) developed by the Boeing Company for managing procedural deviations in maintenance. It provides the first line supervisor and the Safety manager with a structured method for analyzing and tracking the factors leading to maintenance errors and for recommending error prevention strategies.

3.2 Maintenance Error Decision Aid (MEDA) MEDA Five Basic Steps 1. Event; Following an event, it is the responsibility of the maintenance organization to select the error caused aspects that will be investigated.

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2. Decision; After fixing the problem and returning the aircraft to service, the operator decides if the event was maintenance-related. If yes, the operator performs a MEDA investigation. 3. Investigation; Following a structured form (specifically designed for MEDA), the operator carries out an investigation. The investigator records general information with respect to the aircraft, when the maintenance and the event occurred, the event that precipitated the investigation, the error that caused the event, the factors that contributed to the error and possible prevention strategies. 4. Prevention Strategies; Management reviews, prioritizes, implements and then tracks prevention strategies (process improvements) in order to avoid or reduce the likelihood of similar errors occurring in the future. 5. Feedback is provided to the maintenance workforce in order for Maintenance personnel to know that changes have been made to the maintenance system as a result of the MEDA process. Management is responsible for affirming the effectiveness of employees participation and validating their contribution to the MEDA process by sharing investigation results with them. Definitions An error is a human action (or human behavior) that unintentionally deviates from the expected action (or behavior). A violation is a human action (or human behavior) that intentionally deviates from the expected action (or behavior). A contributing factor is anything that affects how a maintenance technician or inspector does his/her job. It is easier to understand the concept of contributing factor using a model:

MEDA Event Model

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In this simple model, a contributing factor causes an error that causes an event.

Above model shows explicitly that there is a probabilistic relationship between contributing factors and an error and between an error and an event. But based on research and experience, there are typically three to five contributing factors to each error. In fact, there are contributing factors to the contributing factors.

This leads to a more refined model as shown above that is Enhanced MEDA Error Model. We also know that there are contributing factors to contributing factors and this leads to Further Enhanced MEDA Error Model as shown below:

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In some cases the violation itself leads directly to the event rather than to an error that leads to an event.

There is one other way in which a violation can contribute to an event.

Of course, both types of violations can contribute to a single event. This is shown below in combined Error and Violation Model

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Thus all of these models put together leads to a final event causation model that includes errors and violations known as Final MEDA Event Model as shown below:

The MEDA Philosophy The MEDA philosophy is based on this event model. The fundamental philosophy behind MEDA is: A maintenance-related event can be caused by an error, by a violation, or by an error/violation combination.

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Maintenance errors are not made on purpose. Maintenance errors are caused by a series of contributing factors. Violations, while intentional, are also caused by contributing factors Most of these error or violation contributing factors are part of an airline process, and, therefore, can be improved so that they do not contribute to future, similar events.

The MEDA Investigation Process The traditional approach in following up on maintenance errors was all too often to identify the event caused by a maintenance error and then to administer discipline to whoever made that error. The MEDA process goes much further (without the disciplinary follow-up unless there has been a deliberate violation of procedures). Having investigated the event caused by a maintenance error and identifying who made the error, MEDA facilitates the following actions: determining those factors which contributed to the error; interviewing the responsible persons (and others if necessary) to obtain all the pertinent information; identifying those organizational or system barriers which failed to prevent the error (and the contributing factors as to why they failed); gathering ideas for process improvement from the responsible persons (and others as applicable); maintaining a maintenance error database; analyzing patterns in maintenance errors; implementing process improvements based on error investigations and analyses; providing feedback to all employees affected by these process improvements;

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MEDA Results Form The MEDA Results Form consists of six sections: Section IGeneral Information Section IIEvent Section IIIMaintenance System Failure Section IVContributing Factors Checklist Section VError Prevention Strategies Section VISummary of Contributing Factors, Error, and Event

MEDA Checklist MEDA checklists facilitate the interview process (i.e. data acquisition) and data storage in a maintenance error database. With a view to understanding the context in which maintenance errors are committed, listed below are ten areas where data should be collected: a) Information. This category includes work cards, maintenance procedures manuals, service bulletins, engineering orders, illustrated parts catalogues and any other written or computerized information provided either internally or by the manufacturer that is considered necessary for the fulfillment of the AMEs job.

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Some of the contributing factors as to why the information was problematic or was not used include: understandability (including format, level of detail, use of language, clarity of illustrations and completeness); availability and accessibility; accuracy, validity and currency; conflicting information; b) Equipment/tools. This category includes all the tools and materials necessary for the correct completion of the maintenance or inspection task. In addition to routine drills, wrenches, screwdrivers, etc., it includes non-destructive test equipment, work-stands, test boxes and special tools identified in the maintenance procedures. Some of the contributing factors as to how equipment or tools can compromise the performance of the AME include: unsafe for use by the AME (e.g. protective devices missing or unstable); unreliable, damaged or worn out; poor layout of controls or displays; mis-calibrated or incorrect scale readings; unsuitable for task; unavailable; cannot be used in intended environment (e.g. space limitations or presence of moisture); instructions missing; too complicated; c) Aircraft design/configuration/parts. This category includes those aspects of individual aircraft design or configuration which limit the AMEs access for maintenance. In addition, it includes replacement parts that are either incorrectly labeled or not available, leading to the use of substitute parts. Contributing factors here that may lead to errors by the AME include: complexity of installation or test procedures; bulk or weight of component; inaccessibility; configuration variability (e.g. due to different models of the same aircraft type or modifications); parts not available or incorrectly labeled; easy to install incorrectly (e.g. due to inadequate feedback, absence of orientation or flow direction indicators, or identical connectors); d) Job/task. This category covers the nature of the work to be completed including the combination and sequence of the various tasks comprising the job.

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Some of the contributing factors conducive to facilitating maintenance errors in this area include: repetitive or monotonous task; complex or confusing task (e.g. long procedure with multiple or concurrent tasks, and exceptional mental or physical effort required); new or changed task; task or procedure varies by aircraft model or maintenance location; e) Technical knowledge/skills. This category includes the operator process knowledge, aircraft system knowledge and maintenance task knowledge, as well as the technical skills to perform the assigned tasks or sub-tasks without error. Some of the related contributing factors compromising job performance are: inadequate skills in spite of training, trouble with memory items, or poor decisionmaking; inadequate task knowledge due to insufficient training or practice; inadequate task planning leading to interrupted procedures or too many scheduled tasks for time available (e.g. failure to get all necessary tools and materials first); inadequate operator process knowledge, perhaps due to inadequate training and orientation (e.g. failure to order necessary parts on time); inadequate aircraft system knowledge (e.g. incomplete post-installation test and fault isolation); f) Individual factors. This category includes the factors affecting individual job performance that vary from person to person, such as those things brought to the job by the individual (e.g. body size/strength, health and personal events), as well as those caused by interpersonal or organizational factors (e.g. peer pressure, time constraints, and fatigue due to the job itself, scheduling or shift work). The following possible factors contributing to maintenance errors: physical health, including sensory acuity, pre-existing disease or injury, chronic pain, medications, and drug or alcohol abuse; fatigue due to task saturation, workload, shift scheduling, lack of sleep or personal factors; time constraints due to fast work pace, resource availability for assigned workload, pressures to meet aircraft gate time, etc.; peer pressures to follow groups unsafe practices, disregard for written information, etc.; complacency (e.g. due to over familiarity with repetitive task, or hazardous attitudes of invulnerability or overconfidence); body size or strength not suitable for reach or strength requirements (e.g. in confined spaces); personal events such as a death of a family member, marital problems, and a change in financial well-being;

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workplace distractions (e.g. due to interruptions in a dynamically changing work environment);

g) Environment/facilities. This category includes all those factors which can not only affect the comfort of the AME but also create health or safety concerns which may become a distraction to the AME. Some of the environmental factors as being potentially contributory to maintenance errors include: high noise levels that compromise communications or feedback, affect concentration, etc.; excessive heat affecting the AMEs ability to physically handle parts or equipment, or causing personal fatigue; prolonged cold that affects the sense of touch or smell; humidity or rain that affects aircraft, part or tool surfaces, including use of paper documents; precipitation affecting visibility or necessitating bulky protective clothing; insufficient lighting for reading instructions or placards, conducting visual inspections or performing tasks; wind affecting ability to hear or communicate, or irritating eyes, ears, nose or throat; vibrations making instrument reading difficult or inducing fatigue in hands or arms; cleanliness affecting ability to perform visual inspections, compromising footing or grip, or reducing available workspace; hazardous or toxic substances affecting sensory acuity, causing headaches, dizziness or other discomfort, or requiring wearing of awkward protective clothing; power sources that are inadequately protected or marked; inadequate ventilation causing personal discomfort or fatigue; workspace too crowded or inefficiently organized; h) Organizational factors. This category includes such factors as internal communication with support organizations, the level of trust that is established between management and Maintenance personnel, awareness and buy-in to managements goals, and union activities. All these factors can affect the quality of work and therefore the scope for maintenance error. The following are some of the organizational factors as being potentially contributory to maintenance errors: quality of support from technical organizations that is inconsistent, late or otherwise poor; company policies that are unfair or inconsistent in their application, inflexible in considering special circumstances, etc.; company work processes, including inappropriate SOPs, inadequate work inspections and outdated manuals; union action that becomes a distraction;

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corporate change (e.g. restructuring) creating uncertainty, relocations, layoffs, demotions, etc;

i) Leadership and supervision. This category is tightly linked to the category on organizational factors. Although supervisors do not normally perform the maintenance tasks, they can contribute to maintenance errors through poor planning, prioritizing and organizing of job tasks. Supervisors and management must provide a vision of where the maintenance function is headed and how it is going to get there; in their daily activities they must walk the talk, i.e. their acts must match their words. Some areas where weaknesses in leadership and supervision can create a work environment conducive to maintenance errors include: inadequate planning or organization of tasks affecting the availability of time or resources to complete work properly; inadequate prioritization of work; inadequate delegation or assignment of tasks; unrealistic attitude or expectations leading to inadequate time to complete the job; excessive or inappropriate supervisory style, second-guessing Maintenance personnel or failing to involve them in decisions affecting them; excessive or aimless meetings; j) Communication. This category refers to any breakdown in (written or oral) communication that prevents the AME from getting the correct information regarding a maintenance task in a timely manner. Listed below are some examples of interfaces between employees where breakdowns in communication occur, thereby creating the potential for maintenance errors: Between departments vague or incomplete written directions, incorrect routing of information, personality conflicts, or failure to pass on timely information; Between Maintenance personnel failure to communicate at all; miscommunication due to language barriers, use of slang or acronyms, etc.; failure to ask questions when understanding is in doubt; or failure to offer suggestions when change is needed; Between shifts inadequate turnovers due to poor (or rushed) verbal briefings, or inadequate maintenance of records (job boards, check-off lists, etc.); Between maintenance crew and lead when the lead fails to pass important information to the crew (including inadequate briefing at start of shift, or feedback on performance); when the crew fails to report problems or opportunities to the lead; or when roles and responsibilities are unclear; Between lead and management when management fails to pass important information to the lead (including discussion of goals and plans, feedback on work completed, etc.); when the lead fails to report problems or opportunities to management; etc.;

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Between the flight crew and maintenance crew vague or incomplete logbook write-up; late notification of defect; aircraft communications addressing and reporting system (ACARS)/data link not used;

4. References
This Manual is in accordance with the following documents: Annex 6 to the Convention on International Civil Aviation, Operation of Aircraft International Civil Aviation Organization (ICAO) Document 9859, ICAO Safety Management Manual Maintenance Error Decision Aid (MEDA) Users Guide developed by Boeing

5. Definitions
Accident an unplanned event or series of events that results in death, injury, occupational illness, damage to or loss of equipment or property, or damage to the environment. Analysis the process of identifying a question or issue to be addressed, modeling the issue, investigating model results, interpreting the results, and possibly making a recommendation. Analysis typically involves using scientific or mathematical methods for evaluation. Assessment process of measuring or judging the value or level of something. Audit scheduled, formal reviews and verifications to evaluate compliance with policy, standards, and/or contractual requirements. The starting point for an audit is the management and operations of the organization, and it moves outward to the organization's activities and products/services. Internal audit an audit conducted by, or on behalf of, the organization being audited. External audit an audit conducted by an entity outside of the organization being audited. Aviation system the functional operation/production system used by the service provider to produce the product/service (see Figure 1). Complete nothing has been omitted and the attributes stated are essential and appropriate to the level of detail. Continuous monitoring uninterrupted watchfulness over the system. Corrective action action to eliminate or mitigate the cause or reduce the effects of a detected nonconformity or other undesirable situation.

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Correct accurately reflects the item with an absence of ambiguity or error in its attributes. Documentation information or meaningful data and its supporting medium (e.g., paper, electronic, etc.). In this context it is distinct from records because it is the written description of policies, processes, procedures, objectives, requirements, authorities, responsibilities, or work instructions. Evaluation a functionally independent review of company policies, procedures, and systems. If accomplished by the company itself, the evaluation should be done by an element of the company other than the one performing the function being evaluated. The evaluation process builds on the concepts of auditing and inspection. An evaluation is an anticipatory process, and is designed to identify and correct potential findings before they occur. An evaluation is synonymous with the term systems audit. Hazard any existing or potential condition that can lead to injury, illness, or death to people; damage to or loss of a system, equipment, or property; or damage to the environment. A hazard is a condition that is a prerequisite to an accident or incident. Incident a near miss episode with minor consequences that could have resulted in greater loss. An unplanned event that could have resulted in an accident, or did result in minor damage, and indicates the existence of, though may not define a hazard or hazardous condition. Lessons learned knowledge or understanding gained by experience, which may be positive, such as a successful test or mission, or negative, such as a mishap or failure. Lessons learned should be developed from information obtained from within, as well as outside of, the organization and/or industry. Likelihood the estimated probability or frequency, in quantitative or qualitative terms, of an occurrence related to the hazard. Line management management structure that operates the aviation system. Nonconformity non fulfillment of a requirement (ref. ISO 9000). This includes but is not limited to noncompliance with Federal regulations. It also includes company requirements, requirements of operator developed risk controls or operator specified policies and procedures. Operational life cycle period of time spanning from implementation of a product/service until it is no longer in use. Oversight a function that ensures the effective promulgation and implementation of the safety-related standards, requirements, regulations, and associated procedures. Safety oversight also ensures that the acceptable level of safety risk is not exceeded in the air transportation system. Safety oversight in the context of the safety management system will be conducted via oversights safety management system (SMS-O). Preventive action action to eliminate or mitigate the cause or reduce the effects of a

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potential nonconformity or other undesirable situation. Procedure specified way to carry out an activity or a process. Process set of interrelated or interacting activities which transform inputs into outputs. Product/service anything that might satisfy a want or need, which is offered in, or can be purchased in, the air transportation system. In this context, administrative or licensing fees paid to the government do not constitute a purchase. Product/service provider any entity that offers or sells a product/service to satisfy a want or need in the air transportation system. In this context, administrative or licensing fees paid to the government do not constitute a purchase. Examples of product/service providers include: aircraft and aircraft parts manufacturers; aircraft operators; maintainers of aircraft, avionics, and air traffic control equipment; educators in the air transportation system; etc. (Note: any entity that is a direct consumer of air navigation services and or operates in the U.S. airspace is included in this classification; examples include: general aviation, military aviation, and public use aircraft operators.) Records evidence of results achieved or activities performed. In this context it is distinct from documentation because records are the documentation of SMS outputs. Residual safety risk the remaining safety risk that exists after all control techniques have been implemented or exhausted, and all controls have been verified. Only verified controls can be used for the assessment of residual safety risk. Risk The composite of predicted severity and likelihood of the potential effect of a hazard in the worst credible system state. Risk Control refers to steps taken to eliminate hazards of to mitigate their effects by reducing severity and/or likelihood of risk associated with those hazards. Safety assurance SMS process management functions that systematically provide confidence that organizational products/services meet or exceed safety requirements. Safety culture the product of individual and group values, attitudes, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, the organization's management of safety. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. Safety Management System (SMS) the formal, top-down business-like approach to managing safety risk. It includes systematic procedures, practices, and policies for the management of safety (as described in this document it includes safety risk management, safety policy, safety assurance, and safety promotion). Product/Service Provider Safety Management System (SMS-P) the SMS owned and operated by a product/service provider. Oversight Safety Management System (SMS-O) the SMS owned and operated by an

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oversight entity. Safety objectives something sought or aimed for, related to safety.
NOTE 1: Safety objectives are generally based on the organizations safety policy. NOTE 2: Safety objectives are generally specified for relevant functions and levels in the organization.

Safety planning part of safety management focused on setting safety objectives and specifying necessary operational processes and related resources to fulfill the quality objectives. Safety risk the composite of predicted severity and likelihood of the potential effect of a hazard. Safety risk control anything that reduces or mitigates the safety risk of a hazard. Safety risk controls must be written in requirements language, measurable, and monitored to ensure effectiveness. Safety risk management (SRM) a formal process within the SMS composed of describing the system, identifying the hazards, assessing the risk, analyzing the risk, and controlling the risk. The SRM process is embedded in the processes used to provide the product/service; it is not a separate/distinct process. Safety promotion a combination of safety culture, training, and data sharing activities that support the implementation and operation of an SMS in an organization Severity the consequence or impact of a hazard in terms of degree of loss or harm. Substitute risk risk unintentionally created as a consequence of safety risk control(s). System an integrated set of constituent elements that are combined in an operational or support environment to accomplish a defined objective. These elements include people, hardware, software, firmware, information, procedures, facilities, services, and other support facets. Top Management (ref. ISO 9000-2000 definition 3.2.7) the person or group of people who directs and controls an organization.

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