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11. Staff Instruction (SI) No. 107-001

Staff Instruction (SI)
No. 107-001

Acceptance Procedures for Phase 2, 3 or 4 of the Safety Management System (SMS) Regulatory Exemption

Internal documents and documents hyperlinked and stored on
Transport Canada's intranet mentioned in this document
are available upon request. See Contact Office below.

Issuing Office:	Standards
Activity Area:	Qualifying	Document No.:	SI 107- 001
File No.:	Z 5015-11-2	Issue No:	05
RDIMS No.:	4732587-V5	Effective Date:	2009-06-05

• 1.0  INTRODUCTION
  • 1.1  Purpose
  • 1.2  Applicability
  • 1.3  Description of Changes
• 2.0  REFERENCES AND REQUIREMENTS
  • 2.1  Reference Documents
  • 2.2  Cancelled Documents
  • 2.3  Definitions and Abbreviations
• 3.0  BACKGROUND
• 4.0  PROCEDURES
  • 4.1  Milestones
  • 4.2  Process Flow Diagrams
  • 4.3  Validation
  • 4.4  Acceptance and Rejection Letter
  • 4.5  SMS Assessments
  • 4.6  Manual Amendments
  • 4.7  Coordinating Manual Amendments
  • 4.8  Compliance Strategy
  • 4.9  RDIMS
  • 4.10  NACIS
• 5.0  CONTACT OFFICE
• APPENDIX A – ACCEPTANCE LETTER TEMPLATE
• APPENDIX B – REJECTION LETTER TEMPLATE

1.0  INTRODUCTION

1.1  Purpose

The purpose of this Staff Instruction (SI) is to detail the procedures for the acceptance of Phase 2, 3 or 4 of the exemption for certificate holders implementing a Safety Management System (SMS). This document provides guidance for Civil Aviation Safety Inspectors (CASI) in the performance of their duties and ensures consistency in the Phase 2, 3 or 4 acceptance processes.

1.2  Applicability

This document is applicable to Civil Aviation Safety Inspectors who are responsible for an organization implementing a SMS. Applicable organizations are those who hold a certificate of operations issued in accordance with subparts 573 and 705 of the Canadian Aviation Regulations  (CARs). Organizations issued a certificate of operation in accordance with subpart 573 of the CARs must hold an aircraft rating for an aircraft type currently operated under subpart 705 of the CARs.

1.3  Description of Changes

1. The appendices in the previous issue of this document have been removed. They are now individual RDIMS documents, which have had minor updates. These include the SMS Documentation Review Guide (RDIMS 4198634), the SMS On-Site Review Guide (RDIMS 4208267), and the SMS Validation Summary Table (RDIMS 4202929).
2. All other changes are minor and of an editorial nature.

2.0  REFERENCES AND REQUIREMENTS

2.1  Reference Documents

1. It is intended that the following reference materials be used in conjunction with this document:
   
   
   1. Part I, Subpart 6 of the CARs—Accountable Executive;
   2. Part I, Subpart 7 of the CARs—Safety Management System Requirements;
   3. Part V, Subpart 73 of the CARs—Approved Maintenance Organizations;
   4. Part VII, Subpart 5 of the CARs—Airline Operations;
   5. Part VII, Subpart 6 of the CARs—Aircraft Maintenance Requirements for Air Operators;
   6. Standard 573 of the CARs—Approved Maintenance Organizations;
   7. Standard 725 of the CARs—Airline Operations – Aeroplanes;
   8. Standard 726 of the CARs—Air Operator Maintenance;
   9. Staff Instruction (SI) SUR-001, Issue 02, 2009-02-06—Safety Management System Assessment and Program Validation Procedures;
   10. Transport Canada Publications, TP 13521, Edition 01, 1999-12-01—Flight 2005: A Civil Aviation Safety Framework for Canada;
   11. Exemption From Certain Canadian Aviation Regulations (CARs) to Facilitate the Implementation of Safety Management Systems by Air Operators, 2005-06-13;
   12. Exemption From Certain CARs to Facilitate the Implementation of Safety Management Systems by Approved Maintenance Organizations, 2005-06-13.
   13. Transport Canada, Records Document and Information Management System (RDIMS) Document No. 4198634—SMS Documentation Review Guide;
   14. RDIMS 4208267—SMS On-site Review Guide; and
   15. RDIMS 4202929—SMS Validation Summary Table.

2.2  Cancelled Documents

Not applicable.

2.3  Definitions and Abbreviations

The following definitions and abbreviations are used in this document:

1. Acceptance Validation means a process comprised of a documentation review and an on-site review to confirm that an element is documented, in place and understood, and is being utilized by the organization under review (no score is assigned);
2. Assessment means a process comprised of a documentation review and on-site review of the entire organization in order to determine if the safety management system is documented, in place and effective (a score is assigned);
3. CASI means Civil Aviation Safety Inspector;
4. Certificate holder means a Transport Canada Civil Aviation (TCCA) certificate holding organization and includes, but is not limited to, air operators, approved maintenance organizations, air navigation system service providers, flight training units, airport or aerodrome operators, manufacturers, engineering organizations and training organizations;
5. Component review means a process comprised of a documentation review and an on-site review of one or more elements of a component to determine if the element are documented, in place and effective (a score is assigned);
6. Days means calendar days;
7. Major discrepancy means that the body of documentation to describe a particular element is missing or cannot be applied as written;
8. Policy means a high level overall plan that outlines the goals and objectives of an organization;
9. Procedure means a specified way to carry out an activity or process;
10. Process means a group of interrelated or interacting activities that convert inputs into outputs;
11. Responsible Manager means the regional manager or Branch director in headquarters who convenes the validation and to whom the SMS Review Team reports;
12. SMS Review Team means a group of persons assigned by their responsible manager to review the Phase 2, 3 or 4 SMS submission of a certificate holder;
13. SMS Team Leader means a person who is assigned the responsibility of coordinating the SMS Phase 2, 3 or 4 acceptance of a certificate holder;
14. TCCA means Transport Canada Civil Aviation; and
15. System means a group of inter-dependent processes and people working together to achieve a defined result. A system comprises policies, processes and procedures.

3.0  BACKGROUND

1. In Flight 2005: A Civil Aviation Safety Framework for Canada, Transport Canada Civil Aviation (TCCA) committed to the implementation of SMS in civil aviation organizations. Safety management is a principal element of a sound aviation management program and a prime factor in the achievement of the goals set out in Flight 2005: the reduction of accidents and incidents and an increased level of public confidence in Canada’s air transportation system. The aim is to improve safety through proactive management rather than reactive compliance with regulatory requirements.
2. TCCA, through the Canadian Aviation Regulatory Advisory Council (CARAC), developed a series of rule changes to introduce the regulatory requirements for Safety Management System (SMS) in civil aviation organizations. Rules affecting Certificate holders in subparts 573 and 705 of the CARs came into force on May 31, 2005.
3. Safety management involves organizational as well as cultural change. TCCA believes that a phased-in approach to SMS implementation is appropriate, providing a manageable series of steps for organizations to follow. Four implementation phases have been identified; each phase involves the introduction of specific SMS components and elements. An exemption has been issued to permit the phased implementation approach.

4.0  PROCEDURES

4.1  Milestones

The following tables describes the important milestones related to the acceptance of Phase 2, 3 or 4 of the SMS exemption, as well as the accompanying actions to be completed by either the certificate holder or the CASI(s).

Table 1—Milestones Phase 2

Date	Action
September 29, 2006	No later than this date, Certificate holders must submit to the Minister documentation that demonstrates that they have developed and documented the following: The Safety Management Plan component (all elements); The following elements of the Safety Oversight component: Reactive Processes; Investigation and Analysis; and Risk Management Training for personnel assigned duties under the SMS that are relevant to the components and elements referred to in (a) and (b). Documented policies and procedures that are relevant to the SMS components and elements referred to in (a), (b) and (c).
December 31, 2006	No later than this date, TCCA will complete a review of the documentation required at the end of Phase 2, at which point TCCA will either: notify the Certificate holders of any omissions or deficiencies; or approve the manual amendments supporting the Phase 2 SMS elements.
January 31, 2007	No later than this date, the Certificate holder shall provide to TCCA the actual corrections to their SMS documentation.
July 31, 2007	No later than this date, TCCA shall perform, to the extent necessary, an on-site review to confirm that the Certificate holders have the required elements in place to proceed to Phase 3.
August 29, 2007	No later than this date, the Minister shall issue a 30-day Notice of Suspension to Certificate holders that fail to meet the requirements of Phase 2 of the exemption.

Table 2—Milestones Phase 3

Date	Action
September 29, 2007	No later than this date, Certificate holders must submit to the Minister documentation that demonstrates that they have developed and documented the following: Proactive Processes The documentation to support Proactive Processes will also include information relating to the following: Identification and Maintenance of Applicable Regulations; SMS Documentation; Records Management; and Training, Awareness and Competence.
December 31, 2007	No later than this date, TCCA will complete a review of the documentation required at the end of Phase 3, at which point TCCA will either: Notify the Certificate holders of any omissions or deficiencies; or Approve the manual amendments supporting the Phase 3 SMS elements.
January 31, 2008	No later than this date, the Certificate holder shall provide to TCCA the actual corrections to their SMS documentation. The Minister shall issue a 30-day Notice of Suspension to Certificate holders that fail to meet this deadline.
July 31, 2008	No later than this date, TCCA shall perform, to the extent necessary, an on-site review to confirm that the Certificate holders have the required elements in place to proceed to Phase 4.
August 29, 2008	No later than this date, the Minister shall issue a 30-day Notice of Suspension to Certificate holders that fail to meet the requirements of Phase 3 of the exemption.

Table 3—Milestones Phase 4

Date	Action
September 29, 2008	No later than this date, Certificate holders must submit to the Minister documentation that demonstrates that they have developed and documented the following: Operational Quality Assurance; Emergency Preparedness and Response; Training for personnel assigned duties under the SMS that are relevant to the components and elements referred to in (a) and (b); and Documented policies and procedures that are relevant to the SMS components and elements referred to in (a), (b) and (c).
December 31, 2008	No later than this date, TCCA will complete a review of the documentation required at the end of Phase 4, at which point TCCA will either: Notify the Certificate holders of any omissions or deficiencies; or Approve the manual amendments supporting the Phase 4 SMS elements.
January 31, 2009	No later than this date, the certificate holder shall provide to TCCA the actual corrections to their SMS documentation. The Minister shall issue a 30-day Notice of Suspension to Certificate holders that fail to meet this deadline.
November 30, 2009	No later than this date, TCCA shall perform a SMS assessment to confirm that the Certificate holders have the required elements in place to demonstrate compliance with the CARs. Refer to section 4.5 of this SI for additional information.
December 29, 2009	No later than this date, the Minister shall issue a 30-day Notice of Suspension to Certificate holders that fail to meet the requirements of Phase 4 of the exemption. Refer to section 5.2.6.6 of SI SUR-001 for additional information regarding the issuance of a Notice of Suspension following a SMS assessment.

4.2  Process Flow Diagrams

The following diagrams demonstrate the Phase 2 and 3 acceptance and Phase 4 assessment process flow. The flow charts are divided into three parts, the first dealing with documentation reviews, the second with on-site reviews and the third with assessment.

Diagram 1—Documentation Review

Click image to enlarge

 

Diagram 2—On-Site Review

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Diagram 3—SMS Assessment

Click image to enlarge

4.3  Validation

1. The SMS Review Team shall perform a validation exercise on the certificate holder under review in accordance with the procedures described in this section. A validation is a two-part process comprising of a documentation review and an on-site review. Its purpose is to confirm that elements of the SMS are:
   
   
   1. documented;
   2. in place and understood; and
   3. utilized by the organization.
2. A validation exercise does not test the effectiveness of the system. The acceptance of Phase 2, 3 or 4 will be based on a satisfactory validation, as determined by the SMS Review Team. Phased components that were validated during prior sessions should not be considered during a new validation unless:
   
   
   1. the component has been amended by the certificate holder;
   2. deficiencies are uncovered during the normal process of a new acceptance validation;
   3. the applicant demonstrates they are not utilizing a previously approved process; or
   4. any safety/compliance issues are present.
3. Team leaders will immediately notify the responsible manager of a condition where previously validated components are a concern. The Certificate holder will be subject to the compliance strategy outlined in section 4.8 of this SI.

4.3.1  Periodic Oversight

At a frequency to be determined by the responsible managers, principal inspectors shall contact Certificate holders to ensure that they are progressing in the development of their SMS and respecting the milestones identified in the project plan, approved as part of Phase I of the exemption.

4.3.2  SMS Review Team

1. Responsible managers shall identify the multidisciplinary teams that will perform the validation on a specific certificate holder. An SMS Team Leader will be assigned overall responsibility for the validation exercise and will be the primary point of contact for both internal and external communications.
2. Team size will vary depending on the size and complexity of the certificate holder, inspector workload and other issues. Principal inspectors may participate as members of the review team during SMS implementation but are not expected to be part of the final assessment team.

4.3.3  Documentation Review

1. The objective of a documentation review is to identify apparent omissions or deficiencies in the submitted documentation. It is not intended to establish if the described policies and procedures are effective. This particular part of the validation is a desktop exercise that does not involve an on-site visit and is intended to confirm that the applicant has documented their program in a manner that meets the requirements.
2. SMS Review Team members should consider two aspects when conducting the documentation review:
   
   
   1. The corporate aspect—does the policy or procedure represent the way things are done across all areas of the organization? and
   2. The individual certificate aspect—is this policy or procedure unique to this particular certificate area?
3. The documentation review provides a focus for planning the on-site review by gaining a general overview and holistic understanding of the certificate holder’s SMS and of its state of preparedness for validation.
4. The major steps of a documentation review, as illustrated in Diagram 1 of this SI, include the following:
   
   
   1. Documentation Review Guide
      
      In preparation for the validation exercise, the SMS Team leader shall provide the certificate holder with the Documentation Review Guide (RDIMS 4198634) and request that they enter the required tombstone information in Part A, as well as the document references and supporting comments in Part B of the document. The SMS Review Team will use Part C and D of the guide to document the results of the documentation review exercise.
      
      Note:
      
      Continuous improvement activities have resulted in several changes to expectations in the Documentation Review Guide. The application of these revised expectations by Certificate holders will be confirmed during the assessment scheduled at the end of Phase 4. CASIs should discuss these revisions with their respective organizations as soon as possible to allow sufficient time for adjustment to affected programs if necessary.
   2. Receipt of the Phase submission
      
      As defined in Table 1, 2 or 3 of the Documentation Review Guide, certificate holders currently implementing SMS are required to submit documentation that demonstrates to the Minister that they have all of the Phase 2, 3 or 4 required elements. Along with their documentation, they are required to submit the completed Documentation Review Guide.
   3. Preliminary Review
      
      The SMS Team Leader will perform a preliminary review of the documentation submitted to verify its completeness. The SMS Team leader is required to pay particular attention to Part A and B of the Documentation Review Guide.
   4. Amendments to previously approved SMS documentation
      
      The SMS Team Leader will make arrangements, provided they are submitted in a timely fashion, to include any amendments to previously validated phase elements submitted by the certificate holder into the review process. For example, previously validated elements will change when documentation/communication is amended to include the current phase or the organization has made changes for continuous improvement. Amendments that are unacceptable will be returned to the certificate holder with a detailed letter explaining why the amendment is unacceptable.
   5. Request for Omitted Documents
      
      The SMS Team leader shall contact the Certificate holder in writing to request any omitted documentation. SMS Team leader must ensure that this communication is performed in a timely manner in order to respect the applicable milestone identified in Table 1, 2 or 3 of the Documentation Review Guide for completing documentation reviews.
   6. Incomplete submissions
      
      Certificate holders that do not provide omitted documentation in the time prescribed by the SMS Team leader shall be issued a Notice of Suspension. The Notice of Suspension will come into effect on the date indicated if they do not satisfy the Conditions for Reinstatement by submitting the requested documentation.
   7. Documentation Review
      
      The SMS Review Team shall complete the documentation review exercise and document the results in Part C of the Documentation Review Guide. Team members are required to clearly identify any discrepancies in the comment section of the Documentation Review Guide. The aim of the documentation review is to ascertain that the Phase 2, 3 or 4 requirements are clearly addressed in the submitted documentation. A general policy statement is not usually enough to satisfy the requirement. SMS Review Team members must verify that there is a policy in place and that it is supported by an appropriately documented process or procedure. The documentation should be complete, comprehensive and appropriately cross-referenced. Although detailed procedures may be referenced in the approved manuals, multiple documents that are incorporated by reference may also be utilized (e.g., an overarching SMS document).
   8. Major and Minor Discrepancies
      
      
      1. All major and minor discrepancies observed by team members shall be recorded in the comment section of Part C of the Documentation Review Guide in detail. The SMS Team Leader must ensure that all team members clearly define the problem area and the reasons why they consider it missing, incomplete, or otherwise deficient. In the case of a major discrepancy, certificate holders shall be given 30 days to make necessary changes to their documentation to bring it in line with the Phase 2, 3 or 4 requirements. In the case of a minor discrepancy, certificate holders shall be given 60 days to make the changes. In no circumstance, is it acceptable to go beyond the published milestone dates listed in Section 4.1, Tables 1, 2 and 3 of this SI.
      2. Certificate holders that submit corrections within the allotted timeframe will have their documentation reviewed. Where the submission is considered inadequate, and they are still within the allotted 30 or 60-day timeframe, they will be given the opportunity to resubmit their corrections to a maximum of three efforts.
      3. Where the allotted time period for corrections has expired and the observation is still valid, a Notice of Suspension shall be issued.
      4. In cases where there is evidence to suggest that a certificate holder’s documentation is wholly inadequate, a 30-day Notice of Suspension shall be issued.
   9. Acceptance of the Documentation Corrections
      
      The SMS Review Team shall review any corrections to the certificate holder’s documentation prior to the dates specified in section 4.1, Tables 1, 2 and 3 of this SI and ensure that the documentation is in line with the requirements of the applicable phase. Certificate holders that do not make appropriate corrections shall be issued a Notice of Suspension.
   10. Conclusion of the Documentation Review
       
       Once the documentation review has been completed to the team’s satisfaction, the SMS Team leader shall complete Part D of the Documentation Review Guide. This sign-off does not constitute an approval of the referenced documentation, but rather indicates that all available company documentation was reviewed against the Phase 2, 3 or 4 requirements and that TCCA can proceed with the on-site portion of the validation exercise.

4.3.4  On-Site Review

1. The objective of an on-site review is to validate observations from the documentation review exercise. This includes the validation of deficiencies in the submitted documentation, as well as verifying that the documented policies and procedures are in place and being used. Again, it is not intended to establish that the described policies and procedures are effective.
2. It is important that team members validate all observations from the documentation review, including observations from well-documented elements and elements that were lacking in details. This will ensure that the SMS Review Team captures a complete picture of the organization’s progress with regards to SMS implementation.
3. The major steps of an on-site review, as illustrated in Diagram 2 of this SI, include the following:
   
   
   1. On-site Review Guide
      
      The On-site Review Guide (RDIMS 4208267) shall be used by the SMS Review Team as a tool for completing the on-site review. Through a series of interviews and observations, the SMS Review Team members shall validate the information for each of the required Phase 2, 3 or 4 elements by comparing the organization against the guide’s expectations. The guide also includes questions that team members can use as a starting point for their interviews. Team members shall document observations and any supporting evidence in the Observation section of the tables.
      
      Note:
      
      When applying the On-site Review Guide information, inspectors should also ensure that their validation includes questions relating to Identification & Maintenance of Applicable Regulations, SMS Documentation, Records Management and Training, Awareness and Competence as it applies to Proactive Processes in Phase 3 and Quality Assurance and Emergency Preparedness and Response in Phase 4.
      
      Continuous improvement activities have resulted in several changes to expectations in the On-site Review Guide. The application of these revised expectations by Certificate holders will be confirmed during the assessment scheduled at the end of Phase 4. CASIs should discuss these revisions with their respective organizations as soon as possible to allow sufficient time for adjustment to affected programs if necessary. Questions to address revised expectations are under development and will be published when completed.
   2. Comparison of On-site Observations to Documentation Review
      
      Using the SMS Validation Summary (RDIMS 4202929) SMS Review Team members shall compare the observations collected on-site to the documentation of Phase 2, 3 or 4 elements previously reviewed. This can be achieved by comparing observations from the On-site Review with the comments in Part C of the Documentation Review Guide.
   3. Amendments
      
      All amendments found to be acceptable during the documentation review exercise will be subject to a comparison as described above. If an amendment is received after the documentation review has occurred it is the Team Leader’s decision whether to include it during the on-site portion. This determination should be based on whether the amendment is considered major or minor.
   4. Discrepancies
      
      
      1. All discrepancies observed by team members shall be recorded in the SMS Validation Summary. SMS Team leaders shall ensure that team members clearly define the problem areas and reference evidence. Team members shall document the fact that observations from the documentation review and the on-site review are compatible.
      2. In the case of a major discrepancy, certificate holders shall be given 30 days to make appropriate changes to their documentation to bring it in line with the Phase 2, 3 or 4 requirements. In the case of a minor discrepancy, they shall be given 60 days to make the appropriate changes.
      3. Certificate holders that submit corrections within the allotted timeframe will have their documentation reviewed. Where the submission is considered inadequate, and they are still within the allotted 30 or 60-day timeframe, they will be given the opportunity to resubmit their corrections to a maximum of three efforts.
      4. Where the allotted time period for corrections has expired and the observation is still valid, a Notice of Suspension shall be issued.
      5. In cases where there is evidence to suggest that a company’s documentation is wholly inadequate a 30-day Notice of Suspension shall be issued.
   5. Acceptance of the Documentation Corrections
      
      The SMS Review Team shall review any corrections to the documented policies and procedures resulting from the on-site review, prior to the applicable milestone identified in section 4.1, Tables 1, 2 or 3 of this SI, and verify that the documentation is in line with Phase 2, 3 or 4 requirements. Certificate holders that do not make appropriate corrections shall be issued a Notice of Suspension.
   6. Conclusion of the On-site Review
      
      Once the on-site review has been completed to the team’s satisfaction, the SMS Team leader shall sign-off the SMS Validation Summary Table. This sign-off does not constitute an approval of the referenced documentation, but rather indicates that all available company documentation was validated on-site and that the SMS Team Leader recommends the issuance of the acceptance letter.

4.4  Acceptance and Rejection Letter

1. Once the validation is complete and all discrepancies have been addressed to the satisfaction of TCCA, the SMS Team Leader shall issue a letter of acceptance for the applicable phase of the exemption. A template of the letter is included in Appendix A.
2. If discrepancies are not satisfactorily addressed, the SMS Team Leader shall issue a letter to that effect to the certificate holder. A template of the rejection letter is included in Appendix B.
   
   Note:
   
   The SMS Team Leader must save the acceptance/rejection letter in Records, Documents and Information Management System (RDIMS) (see section 4.9) and cross-reference the RDIMS link in National Aviation Company Information System (NACIS).

4.5  SMS Assessments

1. Upon completion of the phase 4 documentation review the responsible manager will determine whether to conduct an on-site review or an SMS assessment. The following criteria will be applied when making this determination:
   
   
   1. Where the responsible manager determines that the company under review is marginal he/she may choose to conduct an on-site review. Where this review is not satisfactory the procedures established in section 4.4 of this SI shall apply. If this review is satisfactory, a complete assessment of the company’s SMS will be conducted.
      
      Note:
      
      When determining whether a company is marginal the Responsible Manager should consider a combination of factors including: the quality of the documentation submitted, on-going SMS issues related to phase 2 and 3 implementation activities and any other risk indicator.
   2. Where the responsible manager determines that the company under review has successfully completed the documentation review and that the company’s on-going compliance with the phase 2 and 3 requirements is assured, he/she may choose to conduct a complete SMS assessment in lieu of an on-site review.
   3. Regardless of whether the responsible manager opts for either (a) or (b), a full SMS assessment is still required and must be completed no later than November 30, 2009.
   4. All SMS assessments will be conducted in accordance with the procedures established in SI SUR-001—Safety Management System Assessment and Program Validation Procedures.

4.6  Manual Amendments

1. The implementation of the Phase 2, 3 or 4 SMS elements will require certificate holders to amend their approved manuals. They may choose to develop an overarching SMS manual that is incorporated by reference into their approved manuals, or describe the system within their existing approved manual structure.
2. The principal inspectors shall approve the manual changes based on the completed documentation review exercise.
3. While it is common for approved manuals to be produced under separate cover, there is nothing in the regulations that specifically requires this. Similarly, there is nothing that prevents approved manuals being made up of several different volumes, provided it is clear which parts are TCCA approved and which are under the direct control of the certificate holder.
4. As an example of this, there are many instances where holders of multiple certificates have combined their various manuals into a single volume. The most common situation is where the same person holds both an Air Operator Certificate (AOC) and an Approved Maintenance Organization (AMO) Certificate, and chooses to combine his Maintenance Policy Manual (MPM) and Maintenance Control Manual (MCM) in the same document. The key in all these cases is that the document must be approved as meeting the needs of each applicable certificate.
5. Also, while not essential, it is preferable if the manual contents are clearly identified as to which certificate they are intended to support. Finally, the approved sections should be readily distinguishable from the unapproved sections. This is all in the certificate holder’s best interest, since failure to distinguish adequately between the different certificates and between the approved and unapproved material could result in a single minor non-compliance invalidating all the certificates.
6. When it comes to separating approved and unapproved material, the key is that the approved manual (or sections) must contain the controlling policies, in sufficient detail to establish the limits of authority of any unapproved incorporated documents. That way, TCCA need not approve the incorporated documents before the fact, but can still sample check them during normal oversight activities, to verify that they comply with the broad policies established in the approved documents. The approved sections are not merely a table of contents or a pointer to the incorporated documents—they must actually establish the overall objectives and controlling factors. It should be possible to do that fairly briefly, without getting into detailed procedures.
7. Where approved material is contained in a separate manual, it should not be considered as being incorporated by reference in the usual sense that applies to detailed procedures, but rather as a separate volume of the approved manual that is simply published under different cover.
8. For example, both the MCM and the Company Operations Manual (COM) can indicate that they include common information (such as the SMS policies) and that to avoid duplication, those common items have been located in a separate volume. That SMS volume therefore forms a part of both the MCM and the COM, and as such is jointly approved in support of both certificates. Joint review of all common policies, particularly SMS policies, will ensure that they meet the needs of all aspects of the operation, and also confirm that the system as a whole is sufficiently robust to be capable of supporting the activities of either certificate without the support of the other. For example, the policies should still be effective when the Air Operator obtains maintenance from a third party, or when the AMO performs maintenance for another operator.
9. As a separate issue, any of these approved manuals (i.e. either the COM, MPM or SMS manuals) may also make reference to other (unapproved) documents, containing detailed procedures that support the approved policies.
   
   Note:
   
   When approving manual amendments, principal inspectors should exercise caution when those amendments reference regulations other than the Civil Aviation Regulations (for example, the Canada Labour Code). This is to avoid inadvertently endorsing amendments that may contravene other regulatory requirements that are outside of the CASI delegation of authority.

4.7  Coordinating Manual Amendments

The SMS Team leaders shall coordinate the manual amendments process to ensure that the individual manuals involved are approved by the appropriate principal inspector in a timely fashion. To the extent possible, all manuals should be approved at the same time.

4.8  Compliance Strategy

Failure to respect any requirement of the SMS Phase 2 implementation procedures (e.g., milestone dates) is cause for suspension action. Certificate holders who do not meet specific requirements of Phase 2 and receive a Notice of Suspension can comply with the Conditions for Reinstatement before the effective date of the notice and continue with SMS implementation. Should a certificate holder not satisfy the Conditions for Reinstatement before the effective date of the Notice of Suspension, they can comply with the Conditions for Reinstatement at any time up to the introduction of Phase 3 and continue with SMS implementation. Organizations who take this approach may find the remaining time to comply with Phase 2 requirements insufficient before Phase 3 begins. A certificate holder that is not in compliance with all the requirements of Phase 2 after Phase 3 begins will receive a Notice of Suspension requiring full compliance with section 107.02 of the CARs.

Note:

1. The information above is only applicable to Phase 2 and will not be extended to subsequent Phases.
2. “Immediate Threats to Safety” stand-alone and are not within the scope of this compliance strategy.

4.9  RDIMS

SMS Team Leaders are responsible for saving all documentation related to the Phase 2, 3 and 4 validation exercise in RDIMS. This shall include, but not be limited, to the following:

1. the completed Documentation Review Guide;
2. the completed On-site Review;
3. the completed SMS Validation Summary Table);
4. the Phase 2, 3 or 4 Letter of Acceptance (Appendix A) or Letter of Rejection (Appendix B); and
5. all correspondence related to the phase validation exercise, including e-mails, letters to the organization under review and letters to team members.

4.10  NACIS

SMS Team Leaders are responsible for recording the RDIMS document numbers for the completed validation documentation under the “Remarks” tab of the company detail window. When creating a new remark, Team Leaders must:

1. choose “SMS” as the subject area;
2. enter “SMS Validation” as the subject;
3. identify the document titles in the details area (Documentation Review Guide); and
4. include the completion date of the document and the RDIMS number.

5.0 CONTACT OFFICE

For more information please contact:
Technical & National Programs (AARTT)

Phone: 613-952-7974
Facsimile: 613-952-3298
E-mail: jacqueline.booth@tc.gc.ca

Suggestions for amendment to this document are invited and should be submitted via the Transport Canada Civil Aviation Issues Reporting System (CAIRS) at the following Internet address:

http://www.tc.gc.ca/wcms-sgcw/civilaviation/cairs-755.htm

or by e-mail at: CAIRS_NCR@tc.gc.ca

“Original Signed by D.B. Sherritt, Dated 2009-06-05”

D. B. Sherritt
Director, Standards
Civil Aviation

APPENDIX A—ACCEPTANCE LETTER TEMPLATE

TCCA address

File Number

[Date]

[Name]
[Position]
[Company Name]
[Street Address]
[City], [PROV] [Postal Code]

Dear [Name],

Transport Canada Civil Aviation (TCCA) has completed the review of the Phase__(2, 3 or 4) submission for the implementation of your Safety Management System (SMS). In accordance with the requirements of the regulatory exemption, the SMS Phase__(2, 3 or 4) information contained in your approved manuals was validated and found to be acceptable.

The Phase__(2, 3 or 4) documentation review and on-site review acceptance indicates that you have satisfied the interim steps toward the full implementation of your system. Please note that this acceptance does not constitute an approval of the effectiveness of your SMS, but simply acknowledges that you have satisfied the conditions of the Phase__(2, 3 or 4) requirements of the regulatory exemption. No other legislative requirements are included in this review process. System effectiveness shall only be assessed at the end of the implementation phases using the full TCCA SMS Assessment Protocol.

The assessment of your system will consist of a comprehensive review of the achievements of the processes that make up your system. Therefore, we would encourage you to continually advance your existing phased-in processes as other elements of your system are activated through the implementation phases.

As you have completed this step toward the implementation of your full SMS, we would like to take the opportunity to reflect on SMS and the regulatory setting which surrounds it. SMS is intended to create an environment where operational risks can be managed within the regulatory framework. The Canadian Aviation Regulations (CARs) are the minimum standard of safety, and in situations where there is a divergence between managing operational risks through your SMS and compliance with a regulation, your organization must still demonstrate compliance to that regulation or request an exemption to that regulation.

For further information, please do not hesitate to contact me at (XXX) XXX-XXXX.

Thank you,

 

[Name]
Team Leader,
[Company Name] SMS Review Team
Position title

APPENDIX B – REJECTION LETTER TEMPLATE

TCCA address

File Number

[Date]

[Name]
[Position]
[Company Name]
[Street Address]
[City], [PROV] [Postal Code]

Dear [Name],

Transport Canada Civil Aviation (TCCA) has completed the review of the Phase__(2, 3 or 4) submission for the implementation of your Safety Management System (SMS). In accordance with the requirements of the exemption, the SMS Phase__(2, 3 or 4) information contained in your approved manuals was validated with the result that some areas of incompatibility with the Phase__(2, 3 or 4) information was identified.

TCCA will be able to accept your Phase__(2, 3 or 4) submission after all the incompatibilities identified in the attached document are corrected. These corrections are required no later than_______.

For further information, please do not hesitate to contact me at (XXX) XXX-XXXX.

Thank you,

 

[Name]
Team Leader,
[Company Name] SMS Review Team
Position title

Date modified:

2012-02-27

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