CHAPTER 2

Review of Related Literature and Studies

Several related literature and studies have been made in Asia as well as in the Philippines with
direct and indirect bearing with this thesis entitled, An Assessment of the Safety Management System
undertaken by Civil Aviation Authority of the Philippines.
A brief review of the related literature and studies on both local and foreign are presented.
Local Literature
According to Dr. Matthew J. W. Thomas, Incorporating safety management systems into normal
business operations does appear to reduce accidents and improve safety in high-risk industries. At present,
there have only been a small number of quality empirical evaluations of SMSs and it is unclear as to
whether any individual elements of a SMS have a stronger influence on safety over other elements,
although management commitment and appropriate safety communications do affect attitudes to safety.
Transport organisations that provide an appropriate investment and commitment to a safety management
system should receive a positive return on safety.
A safety management system (SMS) can be defined simply as a planned, documented and
verifiable method of managing hazards and associated risks (Bottomley, 1999).
Further, as the International Civil Aviation Organization (ICAO) defines in a little more detail, a safety
management system involves a systematic approach to managing safety, including the necessary
organisational structures, accountabilities, policies and procedures (ICAO, 2009).
While there are many subtly different opinions on the essential components of an SMS, across all
regulatory domains, the basic common attributes of an SMS include:
1. identification of safety hazards
2. remedial action to maintain safety performance
3. continuous monitoring and regular assessment of safety performance
4. continuous improvement of the overall performance of the SMS (ICAO, 2009).
These definitions imply some form of rigor in the actual development and specification of SMS, and
further imply that such an approach to safety management is built upon a strong foundation of scientific
evidence.

Modern SMS could be defined as an arbitrary collection of activities that were deemed necessary
actions to discharge responsibilities under the new age of the delegated responsibility of self-regulation.
As regulatory bodies shifted from the production of prescriptive regulation to the requirement for
systematic safety management, organisations demanded guidance as to how they could meet these new
regulatory requirements. This occurred somewhat independently within various industries, with some
industries being several years ahead of others. As demonstrated in Figure 1, safety management systems
can be defined as the third age of safety.
Figure 1: The evolution of ultra-safe systems - after Amalberti, as cited in ICAO
(2009).

The transition between the pure prescriptive approach and the modern SMS involved a gradual
evolution in the way in which regulation sought to ensure safe systems of work. Certainly the period
between the 1970s and the 1990s was very much the domain of safety programs that had many
elements, and to some extent many of these were elements of what we now call safety management
systems.
In the stark light of self-regulation, the initial formulation of safety management systems were a
collection of largely common-sense activities which would provide comfort and security to organisations
in the new age of regulatory demands.
Prior to this, and as is largely still the case, there was certainly neither agreed definition nor
specification for what a safety management system entailed. Rather, regulatory bodies aggregated safety
management activities that appeared to be best-practice in order to respond to the operators calls for
just tell me what I have to do to be compliant

In the context of Australian civil aviation, the Civil Aviation Safety Authority (CASA) mandated
under Civil Aviation Orders CAO 82.3 and 82.5 that all regular public transport operators must have in
place a functioning and effective SMS since 2009. Responding to the broad guidance provided by ICAO
with respect to SMS, CASA has developed a detailed framework that stipulates the minimum components
of an SMS (ICAO, 2009).
This regulation is the result of a long process of regulatory development, and industry-specific
training beginning over a decade earlier. In the early 2000s, CASA produced a range of guidance manuals
and training materials pertaining to safety management systems. In many respects, Australia was seen as
an international leader in SMS development in aviation, even if it took some ten years to produce a formal
regulatory requirement for all regular public transport operators.
Figure 2 highlights the 15 core components of an SMS as defined by CASA, grouped under the four key
areas of:

safety policy, objectives and planning

safety risk management

safety training and promotion

safety assurance.

Figure 2: CASA Safety Management System Framework (CASA, 2009)

Operators are provided solid guidance with respect to operationalising the required components on an
SMS through the proliferation of support materials in the form of Civil Aviation advisory publications
(CAAPs) and other training and promotional materials produced by CASA, including a purpose-built
aviation SMS Resource Kit.
The objective of this research investigation is to produce a detailed, rigorous examination of the
published research into the efficacy of safety management systems, safety programs and related
management processes that are applicable to high-reliability transport operations. The review of the
literature seeks to identify what characteristics of these systems are most related to the quality of an
organisations safety management. That is, what evidence exists that various aspects of safety
management systems enhance safety.
The potential contribution to safety for this review is that findings could help organisations
prioritise on those areas most likely to improve safety performance when establishing a SMS. It could
also help the development of future guidance and standards in safety management systems, as well as
guidance for reviewing, auditing or investigating an organisations safety management processes.
Foreign Literature
According to the GCAA, General Civil Aviation Authority, Good safety management is more
than just a legal and moral requirement it has always been common sense to operate aircraft safely.
However, as a consequence of the increasing number of accidents involving human factors, it has been
recognised that accident prevention practices must be expanded to include all persons involved with
aircraft operations. One such method is the newly implemented ICAO Standard requiring the introduction
of an accident prevention and flight safety programme. A safety programme identifies and monitors
operational hazards and faults for the effective management of risk. The purpose of this CAAP is to
provide guidance information to all operators of UAE registered aircraft, regardless of operating category,
on the establishment of an aviation safety programme. It is intended as an introductory resource,
providing the operator with the information needed to make a safety programme work for its organisation.
All operators should be aware that aviation safety is an investmentwith a high return over the long term
and it is management driven.
The responsibilities include the identification and reporting of safety hazards, but may not include
operational or engineering authority. The responsibilities and authority of the Safety Officer and other
operational and engineering appointments must be clear and understood to prevent conflict. For very
small organisations, the Safety Officers role may be part of the duties of the Operations or Engineering
Manager, Chief Pilot, or other line manager. The Safety Officer is responsible for, amongst other things;

(a) Maintenance, reviewand revision of a published safety programme.

(b) Timely advice and assistance on safetymatters to managers at all levels.
(c) Establishment and maintenance of a reporting system for hazards.
(d) Investigating incidents and accidents.
(e) Distribution of safety information.
(f) Briefings and training of staff.
(g) Retention of documentation and data.
There should be a safety action group comprising representatives from flight operations,
maintenance and engineering, ground handling, dispatch and other functional areas. The group should be
chaired, preferably by a senior manager. The membership should be appointed by the accountable
manager. The Safety Officer should keep all records for the group and should prepare agendas and
minutes in cooperation with the chair. The action group should meet at the call of the chair, but in any
case not less than quarterly. The group may approve, reject or recommend action on any matter brought
before it. Review of the minutes and signature by the accountable manager, constitutes approval. The
minutes then become directive. Safety action group records should be maintained by the Safety Officer
and kept for three years.
a) Review status of incidents/accidents, and review actions taken.
(b) Review status of hazard/risk reports, and review actions taken.
(c) Review internal audit reports (if applicable).
(d) Review and approve audit response and actions taken.
(e) Review and resolve any safety matters, which are brought before the group.
Legislation already requires certain incidents and accidents to be reported to the GCAA. While
the GCAA conducts accident and incident investigations, it is clearlyin the interests of the operator to do
so as well. Fortunately accidents occur infrequently; however, incidents are much more common. Any
incident reported should be investigated by a responsible and technically competent person from within
the company, and a report furnished to the Safety Officer and the accountable manager. Incidents not
formally investigated by the GCAA should get special attention. Your company learn from investigating
incidents and is able to remove hazards or strengthen defences as required

Fortunately, the aviation accident rate involving UAE registered aircraft is low. Unfortunately,
one result of this is that very few organisations are prepared for an accident should one occur. Whether a
company survives commercially can depend on how it handles the first few hours and days following an
accident. An emergency response plan outlines in writing what should be done after an accident occurs,
and who is responsible for each action. When the plan is first released, relevant staff should be briefed
about the plan. Appropriate staff should receive training in emergency response procedures. The plan
should be readily available and a copy ofit should be next to the work station of the person who answers
the companys telephone, as this person is most likely to be the first notified of the event
Local Studies
According to

Ramon Benedicto A. Fortunately, the aviation accident rate involving UAE

registered aircraft is low. Unfortunately, one result of this is that very few organizations are prepared for
an accident should one occur. Whether a company survives commercially can depend on how it handles
the first few hours and days following an accident. An emergency response plan outlines in writing what
should be done after an accident occurs, and who is responsible for each action. When the plan is first
released, relevant staff should be briefed about the plan. Appropriate staff should receive training in
emergency response procedures. The plan should be readily available and a copy ofit should be next to
the work station of the person who answers the companys telephone, as this person is most likely to be
the first notified of the event
Aviation in Philippines is growing and the Republic of the Philippines is confident that the
aviation industry in Philippines is safe. We are, however, facing serious challenges. For example,
projected growth in aviation means that maintaining the current low accident rate will result in an
unacceptable number of accidents. The challenge for Transport Philippines and the industry is to find
ways to lower the accident rate even further as the industry grows. Flight 2005: A Civil Aviation Safety
Framework for Philippines identifies six Evolving Directions which represent the principal adjustments
that we need to make over the next few years:
Adopting a data-driven approach to enhancing aviation safety. This includes collecting and making
more accessible the type of data that will support a proactive approach to safety;
Using a risk-based approach to resource allocation to support those activities which will achieve the
greatest safety benefit;
Fostering and strengthening partnerships to put into effect the concept that responsibility for safety is
shared by the regulator and the aviation community;

 Implementing safety management systems in aviation organizations;

Taking account of human and organizational factors in safety management practices; and
Communicating effectively with the aviation community on safety. Implementing safety management
systems is the cornerstone of the evolving directions. All the other directions will evolve within a safety
management system environment. Safety management systems are based on the fact that there will
always be hazards and risks, so proactive management is needed to identify and control these threats to
safety before they lead to mishaps.
The 4Ps of safety management
* Philosophy- Safety management starts with Management Philosophy:
recognizing that there will always be threats to safety;
setting the organizations standards; and
confirming that safety is everyones responsibility.
* Policy- Specifying how safety will be achieved:
clear statements of responsibility, authority, and accountability;
development of organizational processes and structures to incorporate safety goals into every aspect of
the operation; and
development of the skills and knowledge necessary to do the job.
* Procedures- What management wants people to do to execute the policy:
clear direction to all staff;
means for planning, organizing, and controlling; and
means for monitoring and assessing safety status and processes.
* Practices- What really happens on the job:
following well designed, effective procedures;
avoiding the shortcuts that can detract from safety; and

 taking appropriate action when a safety concern is identified.

The organizational structures and activities that make up a safety management system are found
throughout an organization. Every employee contributes to the safety health of the organization. In larger
organizations, safety management activity will be more visible in some departments than in others, but
the system must be integrated into the way things are done throughout the establishment. This will be
achieved by the implementation and continuing support of a coherent safety policy which leads to well
designed procedures.
There are two ways of thinking about safety. Traditionally, safety has been about avoiding costs.
Many organizations have been bankrupted by the cost of a major accident. This makes a strong case for
safety, but cost of occurrences is only part of the story. Research shows that safety and efficiency are
positively linked. Safety pays off in reduced losses and enhanced productivity. Safety is good for
business.
A safety management system will provide an organization with the capacity to anticipate and
address safety issues before they lead to an incident or accident. A safety management system also
provides management with the ability to deal effectively with accidents and near misses so that valuable
lessons are applied to improve safety and efficiency. The safety management system approach reduces
losses and improves productivity. The basic safety process is accomplished in five steps:
1. A safety issue or concern is raised, a hazard is identified, or an incident or accident happens;
2. The concern or event is reported or brought to the attention of management;
3. The event, hazard, or issue is analyzed to determine its cause or source;
4. Corrective action, control or mitigation is developed and implemented; and
5. The corrective action is evaluated to make sure it is effective. If the safety issue is resolved,
the action can be documented and the safety enhancement maintained. If the problem or issue is
not resolved, it should be re-analyzed until it is resolved.
Safety is not accomplished solely by the owner, Chief Executive Officer, orany other individual
in an organization. Safety involves everyone. A positive safety culture is invaluable in encouraging the
kind of behaviour that will enhance safety. Positively re-enforcing safety conscious action sends the
message that management cares about safety.

The best way to establish safety as a core value is to make safety an integral part of the
management plan. This is done by setting safety goals and holding managers and employees accountable
for achieving those goals. To be effective, goal setting requires practical, achievable goals which can be
verified and safety goals are no different. Goals should be set and deadlines for meeting them established.
Managers must follow through and hold those responsible to account for their progress toward the goals.
Success or failure in meeting safety goals should be treated in the same way as success or failure at
meeting any other types of goals. Many organizations hold safety meetings from time to time. This is a
good idea, but if safety is a core value, safety implications should be raised and addressed as a normal
part of doing business. When operational or financial concerns are discussed, associated safety issues
should be considered as well. For instance the selection of new equipment will probably involve
evaluating factors like training, purchase price, operating costs, and maintenance. Safety aspects of the
acquisition should also be considered. Requiring that safety be a part of every management decision
underlines the importance of safety and ensures that safety is a normal part of the way all jobs are done.
Aviation is a dynamic industry and conditions are constantly changing. To alert
management that something has changed, or a new hazard is emerging, organizations need input from all
levels. Employees must have away to report hazards and safety concerns as they become aware of them
and every employee must know how to report their concerns. When an employee reports a concern or
hazard, the report should be acknowledged and analyzed. Acting on reported safety concerns will build
employees confidence in the system. If, however, a reporting system is not maintained and attended to,
people will quickly stop using it. Some organizations will be required by regulation to institute a
reporting system. A system that employees do not trust or use will not fulfill the requirements of the
regulation.
Any safety concern should be reported, but here are some real life examples:
high workload during passenger boarding;
poor communication between operational areas;
crews rushing through checks;
inadequate checklists;
inadequate tool or equipment control;
difficulty obtaining parts;

 feeling fatigued on certain schedules;

NOTAMS not being passed to crew;
in-flight turbulence;
unsafe ground movements;
poor communication within maintenance;
poorly designed task cards;
lack of emergency equipment, procedures and training;
emergency exit paths blocked;
vehicles left in fire lanes or other unauthorized area;unruly passengers;
confusing signs;
poor lighting;
dispatching overloaded aircraft; and
failing to maintain operational control. Not all safety concerns require a special reporting
system. Some should be made on existing paperwork, such as reports or logs. Other hazards
might not fit well into existing reporting systems. It is fairly easy to create a form process.
The report must be analyzed to determine whether there is a real threat to safety and if so, what
needs to be done. When the issue requires action, that information must go to the person who has the
authority to take the action. This preserves the accountability of the safety management system. The
credibility of the system is preserved when the outcome is fed back to the reporter. If it is decided that no
action is appropriate, that information, and the reasons for that decision should be fed back to the reporter.
What really matters is that all staff know how to report safety concerns and that their reports are
acknowledged, analyzed, and resolved in a timely manner.

Foreign Study
According to the Civil Aviation Safety Authority, There has been an increasing trend for
the aviation industry to adopt integrated approach to managing various organizational systems.
Specifically, the trend is to integrate quality, safety and risk management systems.
There are benefits and limitations to integrating these management systems. However, recent
feedback from the Australian aviation industry has shown that the benefits outweigh the limitations.
The problem with a stand-alone Safety Management System run separately to other management
systems is that hazards and errors can be overlooked. As Professor James Reason has shown, hazards and
errors can occur at all levels of an organization, from the cockpit or the shop floor right through to the
boardroom. Seemingly minor errors or hazards in one area can combine with others to result in an
incident or accident. [Reason 2001]
Because error and hazard can occur at all levels of an operation, your Safety Management System
works best if it becomes an integral part of your organizational culture, or the way you do business.
[Hudson 2001]
You should customize your Safety Management System in a way that best integrates it into your
operation
There are many ways to integrate a Safety Management System into your operation. You may
have some elements of a Safety Management System in place already. You should plan to integrate a
Safety Management System into your operation in a way that suits your particular operation. Regardless
of how you incorporate a system for managing safety, you should consider each of the 10 key steps which
research has found to be essential to the success of Safety Management Systems.
The 10 basic steps to establishing a Safety Management System are:
1. Gain senior management commitment.
2. Set safety management policies and objectives.
3. Appoint a safety officer.
4. Set up a safety committee (usually only for large or complex organizations).
5. Establish a process to manage risks.

6. Set up a reporting system to record hazards, risks and actions taken.

7. Train and educate staff.
8. Audit your operation and investigate incidents and accidents.
9. Set up a system to control documentation and data.
10. Evaluate how the system is working.
Integrated Safety Management Systems can benefit your operations. The application of the
system depends on the size and nature of your operation. By customizing your Safety Management
System to the way you do business you can ensure ownership of the process. Management commitment,
effective two-way communication and a positive safety culture are the foundations for success
Effective safety management systems contribute to successful business performance by involving
people at all levels to:
Set objectives, policy and procedures for safe operations.
Set responsibilities, accountabilities and authorities for safety action.
Report safety concerns.
Identify and minimise hazards and risk within the work place.
Maintain document control.
Participate in and improve the standards of safety performance.
Monitor and evaluate the safety health of your operation.
Integrating safety, quality and risk management systems provides a cost
effective approach to protecting the resources of your operation