Safety management

This material provides guidance and tools for implementing a simplified mechanism for the collection, evaluation, processing, analysis and storage of details of occurrences and it applies to small organisations in accordance with criteria established in this material.

Some small organizations may feel that Occurrence reporting mechanism is too complex or too costly to implement. We believe, however, that even small organizations already have many of the elements of occurrence reporting obligations in place.

As highlighted earlier, Regulation 376/2014 foresees to join or merge functions related to occurrence handling within the organisation, to share occurrence reporting tasks with other organisations of the same nature or to outsource the collection, evaluation, processing, analysis and storage of details of occurrences to specialised entities approved by the competent authorities of the Member States.

Practical submission of Occurrence reports and their follow-up is facilitated by European Commission through Aviation Safety Reporting portal - https://www.aviationreporting.eu/AviationReporting/

Occurrence reports submitted through this centralised portal is acceptable to LV CAA. Also on ad hoc basis LV CAA can agree to receive occurrence reports and follow-up in non-ECCAIRS compatible format, provided that Quality and content of occurrence reports is maintained.

You do need to document your Occurrence reporting mechanism, but you probably have some of the documentation already, and the rest should be fairly easy to put in place. Consider naming your key safety personnel responsible for dealing with Occurrences. You will need some documentation about your incident investigations and so on. If Management system is not obligatory to your organisation, consider describing Occurrence reporting in a light form of SMS Manual; it might be a very short, simple document mainly referencing your existing procedures, or you might just add a section to your operating manual. Safety Management International Collaboration Group (SM ICG) provides examples.

For small organisations clear and concise documentation ensures that everyone including your staff members, your contractors, and your regulator understand your business. You can use existing manuals or procedures, but do not simply copy them. Yours should be a living document that reflects the structure, the processes and the features of your organization.

Typically safety documentation (SMS manual) includes records such as:

•  Records of audits, safety meetings and management reviews;
•  Records of risk assessments; and
•  A Hazard log or risk register with records of actions,

Which is inevitably linked to Occurrence reporting system.

A Small organization should have a reporting policy so that everyone has a clear understanding of the organization’s values regarding the reporting of safety-related information and how it encourages a healthy reporting culture. For Very Small organizations, a separate reporting policy may not be required if individuals are intimately involved in most aspects of the organization’s operations and employees feel free to report safety-related information.

In a Small organization, the reporting policy could be combined with the Safety Policy and should:

•  Encourage employees to report hazards, incidents or accidents; and
•  Define the conditions under which punitive disciplinary action would be considered (e.g., illegal activity, negligence, wilful misconduct).

For a sample Safety Reporting Policy refer to SM ICG online publications.

Remember to deliver the message that personnel reporting safety-related issues shall not be subject to disciplinary action except where there is clear evidence of:

• Gross negligence;
•  Intentional disregard of regulations or procedures;
•  Attempted cover up;
•  Criminal intent; or
•  Use of illicit substances.

There are times when further investigation of a safety issue is necessary to determine the exact cause and the contributing factors. You do not want to develop a corrective action only to find you have not solved the underlying problem. Using a root cause analysis method for investigations will help to get to the main issue that is causing your problems.

You may not have the time or resources to investigate everything that is reported, so it is best to define when you will investigate an issue. For example, it does not make sense to investigate a problem that is of negligible consequence, but you would certainly want to investigate a problem that is both likely and potentially serious.

A simple approach is to review the safety reports and any operational occurrences and then use the risk matrix to assess the need to investigate. Document the investigation and add the outcomes to the Hazard Log. The following is a generic investigation approach.

Gather information:

• What happened, when, and where?
• What is the impact on the organization?
• What were the conditions and actions that led to the safety issue?
• Who was involved?

Interview those involved.

Analyze the information:

•  Examine all the facts and determine what happened and why (the root causes).
•  Assess whether this event or something similar has happened before
•  Identify contributory factors, such as:

Job factors (e.g., Did the work require too much or too little attention? Were there distractions or conflicting demands? Were the procedures adequate and properly understood?);

Human factors (e.g., physical ability (size and strength), competence (knowledge, skill and experience), fatigue, stress, morale, alcohol or drugs);

Organizational factors (e.g., work pressure, long hours, availability of sufficient resources, quality of supervision, safety culture);

Plant and equipment factors (e.g.. clarity of the controls and instrumentation, layout, the role of unusual circumstances); and

Unsafe acts: Most safety issues are caused by unsafe acts whether deliberate or unintentional. By identifying unsafe acts and understanding what drives them you can establish a lasting and valuable safety culture.

Identify suitable corrective actions.

Draw up the action plan and implement it:

•  Corrective actions may need to be prioritized due to resources and practical implementation timescales. Keep employees fully informed of the corrective action plan and progress with its implementation.

Upon completion of the investigation using this example or another method, you should document the results of the investigation and summarize on the Hazard Log for tracking purposes and to identify any follow up activities. Follow up is needed to ensure the problem has been corrected or adequately controlled.

Even if your organisation is not required to have a Management system, consider establishing a process to identify what could happen as a result of each safety issue (the consequence) and assess how bad the outcome will be and the likelihood of it happening (the risk). Risk assessment, put simply, is determining whether you can accept the risk as it is; if not, you must do something to reduce it (control or mitigation).

A risk matrix may be useful, but in a Very Small to Small organization, it may not be necessary.

NB! Remember, that you that when your organisation identifies an actual or potential aviation safety risk as a result of analysis of occurrences or group of occurrences reported you shall transmit to the competent authority (LV CAA), within 30 days from the date of notification of the occurrence by the reporter

(a) the preliminary results of the analysis performed, if any; and

(b) any action to be taken.

Keep the safety message alive and well; tell your people, tell your customers, tell everyone!

Information contained in occurrence reports should be analysed, and safety risks identified. Any appropriate consequent action for improving aviation safety should be identified and implemented in a timely manner. Information on the analysis and follow-up of occurrences should be disseminated within organisation, sent to LV CAA (and EASA if applicable), since providing feedback on occurrences that have been reported incentivises individuals to report occurrences.

Such feedback should comply with the rules on confidentiality and protection of the reporter and the persons mentioned in occurrence reports pursuant to this Regulation.

Should you have any questions or comments, contact LV CAA Safety Information and Data Section (SIDD) on by looking up the contacts tab on www.caa.gov.lv

For more information and guidance, please refer to “SMS for Small Organizations” provided by SMCIG (www.skybrary.aero/index.php/SMS_for_Small_Organizations)