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TP 14343 - Implementation Procedures Guide for Air Operators and Approved Maintenance Organizations

Foreword

This Implementation Procedures Guide has been developed to assist organizations with the implementation of their Safety Management System (SMS). The guide is designed to address a phased implementation approach and is based on the issuance of Exemptions. The phased approach will allow organizations the time they need to implement safety management in a planned, systematic way. It will also allow Transport Canada civil aviation safety inspectors a means to effectively manage the workload associated with this program.

This guide will also provide information to assist organizations with the selection of an accountable executive.

Not all organizations are required to implement safety management systems at the same time. Organizations that are subject to SMS regulations at a later date are encouraged to begin work on their programs early. Transport Canada will assist organizations wherever possible, however, the priority will be directed to organizations that are required through regulatory amendments, to implement a safety management system.

IMPLEMENTATION PROCEDURES FOR SAFETY MANAGEMENT SYSTEMS

1.1 Purpose

This implementation procedures guide has been developed with a dual purpose, the first is to provide information to Air Operators and Approved Maintenance Organizations (AMO) who are required to implement a Safety Management System (SMS) and the second is to provide information that will assist those organizations with the selection and appointment of an accountable executive.

The guide will offer information on the conduct of a gap analysis and creation of a project plan. It will also expand on Transport Canada's phased-in approach for SMS implementation through the issuance of exemptions. Several forms and examples are also included and can be used or amended to suit the needs of individual organizations.

This guide is intended as information only, if there is a discrepancy between this guide and the applicable regulations, standards or exemption, the regulation, standard or exemption will take precedence.

1.2 Background

In Flight 2005: A Civil Aviation Safety Framework for Canada, Transport Canada committed to the implementation of safety management systems 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.

Transport Canada, through the Canadian Aviation Regulatory Advisory Council (CARAC), has developed a series of rule changes to introduce the regulatory requirements for SMS in civil aviation organizations. These rules will be published in the Canada Gazette II in a staggered fashion. Rules affecting certificate holders in Subpart 73 of Part V and Subpart 705 of Part VII are expected to come into force in 2005. The remaining rules for Part IV, V and Part VII are expected to come into force in 2007. This guide will provide information for the implementation of all the proposed SMS regulations.

Safety management involves organizational as well as cultural change. Transport Canada 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. Exemptions will be issued to permit the phased implementation approach.

As you read this guide it is important to remember that the implementation of SMS depends on the date the regulations come into force. The exemption and the four implementation phases are all predicated on the date of publication of the regulations. Please refer to the Regulatory Affairs website http://www.tc.gc.ca/eng/civilaviation/regserv/affairs-menu-730.htm for further information on when specific regulations will come into force.



1.3 New Entrants

Organizations applying for an Air Operator or AMO Certificate on or after the date the SMS regulations come into force must incorporate all the SMS components and elements as part of their initial application for certification. Existing certificate holders or new entrants, whose application is dated and accepted by Transport Canada prior to the date the SMS regulations come into force, will have the opportunity to utilize the exemption.

Post certification audits for new entrants will be scheduled by the applicable Transport Canada Centre/Office of Primary Interest and will include an assessment of the SMS.

1.4 Safety Management Systems Framework

Transport Canada has developed a SMS framework that is outlined in Table A. This framework follows the same structure as the Transport Canada SMS model, previously published in TP 13881 E. The framework lists six components and corresponding elements.

Table A - This table is included for information purposes and as a reference for Phases 1 through 4.

Table A - SMS Framework
Component Element Phase
Safety Management System Compliance Document, Gap Analysis, Project Plan 1
1. Safety Management Plan 1.1 Safety Policy 2
1.2 Non-Punitive Reporting Policy 2
1.3 Roles, Responsibilities & Employee Involvement 2
1.4 Communication 2
1.5 Safety Planning, Objectives and Goals 2
1.6 Performance Measurement 2
1.7 Management Review 2
2. Document Management 2.1 Identification and Maintenance of Applicable Regulations 2,3,4 **
2.2 SMS Documentation 2,3,4 **
2.3 Records Management 2,3,4 **
3. Safety Oversight 3.1 Reactive Processes 2
3.2 Proactive Processes 3
3.3 Investigation and Analysis 2
3.4 Risk Management 2
4. Training 4.1 Training, Awareness and Competence 2,3,4 **
5. Quality Assurance 5.1 Operational Quality Assurance 4
6. Emergency Preparedness 6.1 Emergency Preparedness and Response 4

** The Document Management and Training components are common to all phases and are implemented as they apply to the other components or elements in that phase.

1.5 The Exemption Process

Upon publication of the SMS regulations in the Canada Gazette Part II, Transport Canada will issue exemptions effectively delaying the requirement for organizations to comply with these new rules. The exemptions will provide all the information needed for organizations to determine who is affected by the SMS regulations and when they are required to comply with the stated conditions.

Note: Refer to the Regulatory Affairs website at http://www.tc.gc.ca /civilaviation/regserv/affairs/menu.htm for official copies of exemptions.

The initial implementation of SMS will only apply to air operators whose operating certificate was issued under Subpart 705 and AMOs whose maintenance organization certificate was issued with aircraft ratings for types operated under Subpart 705. Additional exemptions will be issued at a later date to bring the remaining air operators and AMOs into compliance with forthcoming SMS regulations.

The exemptions will specify that affected organizations must implement a SMS in accordance with the stated conditions. The implementation of the SMS requirements has been divided into four phases with each phase having specific requirements as detailed below.

Transport Canada's experience with SMS implementation activities has demonstrated that cultural as well as organizational change is required to successfully implement a SMS. This takes time, resources and experience. As such, organizations are strongly advised to take full advantage of the exemption program.

1.5.1 Phase 1

During this phase, and no later than the time specified by the Minister in the exemption, affected organizations are required to complete a copy of the Compliance Document (Appendix A) and forward this to their PMI or POI as applicable. Completion of the compliance document will satisfy the requirements of CAR 106.02(1)(c) and is an essential element of the SMS implementation process ensuring that all affected organizations are aware of their regulatory responsibility.

The compliance document will identify the accountable executive and, once completed, will confirm that the individual accepts the responsibilities of their position. It will also identify the person within the organization who is responsible for implementing the SMS and will contain a statement committing the organization to implementing that system. In some organizations, the accountable executive and the person responsible for implementation of the SMS may be the same person.

In addition to completing the compliance document, affected organizations will;

  1. conduct a gap analysis of the organization's existing systems compared to the CARs SMS requirements; and
  2. develop a project plan that clearly demonstrates to the POI/PMI how the organization will implement their SMS based on the requirements of the exemption and the results of the gap analysis.

The project plan will be jointly agreed to between Transport Canada and the organization implementing the SMS. To be effective, the project plan will include milestones for critical items such as dates for development and submission of policies and procedures, training of staff and review by Transport Canada. These milestone dates are important, as principal inspectors will use them to plan their implementation responsibilities and commitments. It is acknowledged that project plans will require some flexibility, both TC and the affected organization must agree to any changes provided they do not permit extension beyond the time limitations of any phase. Last minute changes made to the plan may not be accommodated by Transport Canada due to workload or other priorities.

The compliance document, gap analysis and project plan shall be completed and submitted as a package within the time limitations specified in the exemption. Transport Canada will review the submission and provide a response within 90 days. Transport Canada's endorsement of the compliance document will indicate review of the gap analysis and agreement with the project plan.

1.5.2 Phase 2

During this phase, and no later than the time specified by the Minister in the exemption, certificate holders must demonstrate to the satisfaction of Transport Canada, that they have the following SMS components/elements in place:

  1. The Safety Management Plan component (including all elements);
  2. The following elements of the Safety Oversight component:
    1. Reactive Processes
    2. Investigation and Analysis
    3. Risk Management
  3. Training for personnel assigned duties under the SMS that are relevant to the components and elements referred to in (a) and (b).
  4. Documented policies and procedures that are relevant to the SMS components and elements referred to in (a), (b) and (c).

1.5.3 Phase 3

During this phase, and no later than the time specified by the Minister in the exemption, in addition to meeting the requirements of Phase 2, certificate holders must demonstrate to Transport Canada that they have the Proactive Process element of the Safety Oversight component in place. This requirement will also include documented policies, procedures and training for personnel assigned duties under the SMS.

1.5.4 Phase 4

During this phase, and no later than the time specified by the Minister in the exemption, in addition to meeting the requirements of Phases 2 and 3, certificate holders must demonstrate to the satisfaction of Transport Canada, that they have the following components in place:

  1. Operational Quality Assurance
  2. Emergency Preparedness and Response, and
  3. Training for personnel assigned duties under the SMS that are relevant to the components and elements referred to in (a) and (b).
  4. Documented policies and procedures that are relevant to the SMS components and elements referred to in (a), (b) and (c).

1.6 Gap Analysis and Project Plan

Phase one of SMS implementation requires affected organizations to conduct a gap analysis of their system(s) to determine which components and elements of a safety management system are currently in place and which components or elements must be added or modified to meet the regulatory requirements. The review involves comparing the SMS requirements found in Parts I, V and VII of the CARs against the existing systems in your company. Part I - General Provisions, contains several rule changes that are common to all civil aviation organizations and should be included in the analysis. Any additional SMS requirements can be found in Parts V & VII of the CARs.

Transport Canada has developed a Safety Management Systems Assessment Guide, TP 14326E, which will assist organizations in conducting their criteria linked to the appropriate regulation or standard. The SMS Assessment Guide will be appended to the Inspection & Audit Manual, TP 8606, and will form the basis of Transport Canada's on going SMS evaluations.

A comprehensive gap analysis form is included in this guide as Appendix B. The form combines the criteria from the SMS Assessment Guide, TP14326E, as well as the applicable references to the regulations and standards for Parts I, V & VII. Organizations can use this format as a template to conduct their gap analysis or they can create their own provided they refer to the SMS Assessment Guide for the appropriate criteria for each component and element.

Each gap analysis question is designed for a "yes" or "no" response. If you respond with a "yes" answer you are indicating that your organization already meets the criteria for that particular SMS component or element. A "No" answer indicates that a gap exists between the stated criteria and your organization's policies, procedures or processes. If the response is '"yes", the next column of the gap analysis form can be used to indicate where (in company documentation) the requirement is addressed. If the response is "no", the same column can be used to indicate how and/or where the policy, procedure or process will be further developed to bring the organization into compliance with the requirement.

Once the gap analysis is complete and fully documented, the items you have identified as missing or deficient will form the basis of your project plan. Organizations may format their project plan to suit their individual needs, however, a spreadsheet format or MS Project type layout is recommended for ease of viewing and tracking. Each item will be assessed to determine how the organization will create or modify policies, procedures or processes to incorporate the required SMS components and elements. Components and elements can be grouped into larger projects and assigned to project manager(s) who will oversee the development and implementation of that project. Each component, element or project should be assigned milestones including a termination date to ensure that completion does not fall outside the time limits published in the exemption. Appendix C provides a project plan example with suggested headings to assist organizations in the development of their plan.

Once complete, the compliance document, gap analysis and project plan will be submitted to your POI/PMI no later than the time specified in the exemption. These documents will be reviewed in accordance with the requirements of the exemption and the applicable SMS regulations and standards.

Circumstances that necessitate change(s) to the project plan must be communicated as soon as possible to the assigned principal maintenance or operations inspector to gain agreement and ensure timely submission of required material. Periodic progress reporting is a key component of this process.

1.7 Accountable Executive

Coincident with the introduction of SMS regulations, organizations will also be required to appoint an accountable executive. The accountable executive will be a single, identifiable person within each organization who will assume full responsibility for the organization's ongoing compliance with the CARs (ref CAR 106). It is imperative that the correct person is identified as the accountable executive, and that the individual understands and accepts the roles and responsibilities associated with that position. This is not intended to be a position title without accountability.

Appendices D and E provide a flow chart and series of questions respectively, to assist with the selection process. The flow chart identifies several organizational structures that will lead to a corresponding accountable executive. Once this person is determined, the questions following the flow chart will confirm the selected person is the correct choice. All questions must receive a 'yes' answer for the candidate to be acceptable. Should any of the questions result in a 'no' answer, the selection process must start again with a new candidate. The organizational structures included in the Appendix are intended to cover the majority of situations that will be encountered. Should there be an organizational structure that does not result in the clear selection of an accountable executive, an appropriate candidate will be selected in consultation with Transport Canada. The nomination of the Accountable Executive will be validated during the next inspection, regulatory audit or safety management system assessment.

Note: Regulations requiring the appointment of an accountable executive are separate from those requiring a SMS. Information on the accountable executive is included here to offer organizations a comprehensive package for implementing their SMS and selecting their accountable executive.

1.8 Multiple Certificate Holders

Organizations holding Air Operator and AMO Certificates may choose to implement a single safety management system. This format is optional and will allow the safety management system to be designed to accommodate the regulatory requirements of both certificates. This will ensure that the SMS will be a fully integrated system and not separate systems operating independently of each other.

This is not to imply that the regulatory requirements within each certificate will be combined. Each certificate must continue to comply with its regulatory requirements, however both certificates can be subject to a single SMS.

1.9 Opting out of the Exemption

Organizations that do not take advantage of the exemption(s) must be in full compliance with the applicable safety management regulations within 30 days of publication in the Canada Gazette II. Contact your POI/PMI as soon as possible to ensure your programs, including approved documentation, are compliant with the applicable SMS requirements. Organizations that are found to be non-compliant following an assessment will be subject to normal administrative action.

Due to the anticipated increase in workload expected with SMS implementation, Transport Canada's priority will be directed toward those organizations that utilize the exemption and phased implementation method. As such, organizations are strongly encouraged to take full advantage of the exemption

1.10 Assessment Protocol

The Civil Aviation SMS Assessment Protocol has been developed to give Transport Canada a tool for systematically evaluating the state of Safety Management Systems. It is not meant to be an inspection or compliance audit, but rather, the assessment focuses on the effectiveness and efficiency of a management system and makes judgments on its performance. Civil Aviation Safety Inspectors will use the tool for the review and acceptance of each organization's SMS. This protocol can also be used by affected organizations to "self assess" their program prior to review by Transport Canada. The assessment protocol can be found using the website link provided below under Guidance Material and will be added to the Inspection and Audit Manual (TP 8606).

1.11 Guidance Material

Transport Canada has published additional guidance material to assist organizations with their SMS program. This information is available on the Transport Canada website at http://www.tc.gc.ca/eng/civilaviation/standards/sms-menu-618.htm

Organizations are encouraged to review this site with emphasis on the following;

Safety Management Systems for Flight Operations And Aircraft Maintenance Organizations - A guide to implementation, TP 13881 http://www.tc.gc.ca/eng/civilaviation/standards/sms-menu-618.htm

Safety Management Systems for Small Aviation Operations, TP 14135 (http://www.tc.gc.ca/eng/civilaviation/publications/tp14135-1-menu-2078.htm)

Regulatory Affairs http://www.tc.gc.ca/eng/civilaviation/regserv/affairs-menu-730.htm