BCAA Procedure Manual SMS INTERFACE for ATO (SIA) · BCAA Procedure Manual SMS INTERFACE for ATO ... the civil aviation industry adopted this, ... it will be used for comparison purposes

BCAA Guidance Material for use of the Open-source Microsoft

Excel Interface for SMS (Safety Management System) for ATO

(EASA Approved Training Organizations)

BCAA Procedure Manual

SMS INTERFACE for ATO (SIA)

BELGIAN CIVIL AVIATION AUTHORITY

EUROPEAN UNION

BCAA Procedure Manual SIA Revision original 2

0.1. Table of Contents:

0.1. Table of content ......................................................................................................................................... 2

0.2. List of Effective Pages ................................................................................................................................. 3

0.3. Validity of the document ............................................................................................................................. 4

0.4. Record of revision ........................................................................................................................................ 5

0.5. Legal disclaimer ........................................................................................................................................... 5

0.6. Intro ............................................................................................................................................................. 6

0.7. Abbreviations .............................................................................................................................................. 8

CHAPTER 1: Legal basis ..................................................................................................................... 10

CHAPTER 2: General conditions ........................................................................................................ 11

CHAPTER 3: Concept.......................................................................................................................... 12

3.1. Different TAB’s ..................................................................................................................... 12

3.2. BCAA requirements in the use of SIA ................................................................................... 14

CHAPTER 4: Getting started with SIA ................................................................................................ 15

4.1 STEP 1: Annual Risk Assessment ........................................................................................... 15

4.2 STEP 2: Follow-up of occurrences ......................................................................................... 16

4.3 STEP 3: Safety Meeting ......................................................................................................... 16

4.4 STEP 4: Follow-up .................................................................................................................. 17

4.5 STEP 5: Safety Planning ....................................................................................................... 17

4.6 STEP 6: Safety briefing & promotion ................................................................................... 17

4.7 STEP 7: Management of change ......................................................................................... 17

4.8 STEP 8: Use of SIA as a Management tool .......................................................................... 18

CHAPTER 5: Feedback of SIA to BCAA ................................................................................................ 19


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0.3. Validity of the document:

Prepared by Name Signature Date

Responsible for the document Jelle Vanderhaeghe

01/01/2017

Approved by Name Signature Date

Head of Licensing Directorate Philippe D’homme

Head of Training Department Olivier Grisel

Seal of the authority


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0.4. Record of revisions:

Revision

number

Revision

date: Description of change: Pages: Performed by:

ORIGINAL 01/01/2017 Composition of original document ALL Jelle Vanderhaeghe

0.5. Legal disclaimer:

This document is composed to provide guidelines to the users of the BCAA SMS Interface for ATO (SIA). There

is no legal obligation to follow these guidelines, but all explained in this document are best practices to ensure

a minimum level of SMS in the organizations active in pilot training in Belgian civil aviation. All other training

organizations (non-Belgian, or non-European) are free to use the interface, as long as it is approved by their

respective Competent Authorities of Oversight. This tool is aimed at enhancing aviation safety and is offered

for free to anyone who want to use it for that purpose. BCAA accepts no liability, or responsibility whatsoever

in case of air accidents or incidents, caused by, or involving users of this open-source interface.


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0.6. Intro:

When inquiring crashes involving a certain type of aircraft of the 1940’ies and fifties, like for example the

Lockheed Constellation, the lists and image one can find on the internet, are endless. The number of

spectacular, but also lethal accidents that occurred with this new form of common transport, via the air, just

after the Second World War, made ICAO (the International Civil Aviation Organization, under the UN) to

instate Annex 13 to the Chicago Convention, on Air Accident Investigation, imposing all Member States to

inquire each Air Accident, or Incident in a standardized fashion. Ever since this approach a lot has been

learned from each Air Accident: From the Tenerife collision of 2 Jumbo Jets in 1977 resulted in the

implementation of ground radar, the PF/PM (Pilot Flying/Pilot Monitoring) & CRM-concept, as well as more

strict adherence to standard ICAO R/T-phraseology, just to name one example.

This “reactive” approach to Air Accidents and Incidents has significantly reduced the numbers of Air Accidents

but unfortunately the improvements are usually only established after a great loss of life (the example above

lead to the deaths of 583 people). Such an approach was common in aviation until a few years ago, but would

be unimaginable in other, but similar higher risk environments like the Nuclear and the Pharmaceutical

Industry, where the slightest mistake can cause a multitude of casualties. For years a more proactive

approach towards safety was applied in those domains.

When investigating accidents (not only in aviation) a common trait is that “the signs where there” already

way before the accident occurred. A number of hazards that were previously avoided successfully when they

occurred individually, may lead to a catastrophe, when they occur in a combined manner, on a less fortunate

day. Safety Management is based on identifying all possible hazards and indicators that someday could

contribute to an Air Incident, of Accident and manage them to avoid incidents and accidents.

With ICAO ANNEX 18 (SMS/SSP) the civil aviation industry adopted this, more pro-active approach to safety.

Rather than awaiting accidents, both the Competent Authorities and Organizations are now legally obliged

to deal with Aviation Safety, identify and mitigate hazards, follow-up occurrences and improve their systems,

procedures and training. It also requires greater involvement form the Competent Authorities in the flying

community in a less punitive, but more understanding/enabling role (“Just Culture”), free of blame, not to

revoke/limit/suspend licenses, but so all the aviation community can learn from honest mistakes, or

involuntary occurrences that happened to pilots.


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In the light of European Air Crew Regulations (EU Regulations 1178/2011 and its amendments), more

commonly known as “PART-FCL”, and the EU Regulations 376/2012 & 1018/2015, regulating occurrence

reporting in the European Airspace, the set-up and Management of a Safety System has become mandatory

for all EASA ATO (Approved Training Organizations).

As the principles of SMS were also new to BCAA in 2011, it was difficult to set-up guidelines right away

regarding SMS (implementation of EASA Air Crew Regulations needed our focus elsewhere). Having seen a

lot of noble initiatives and a lot of hard work and investments by ATO and other organizations, BCAA Training

Department observed the following systematically, during SMS-audits: 1. Almost never was the full-scope of

SMS realized. A fully developed SMS is a variety of activities: proactive hazard identification and mitigation,

occurrence follow-up and reporting, optimizing procedures and systems, safety promotion and providing

feedback to stimulate the reporting culture, managing the changes to the organization, etc. 2. Although the

basic principles are quite clear, every organization set-up their own system, with own philosophy and

highlights, leading to A. Loss of standardization and B. Inability to compare, or obtain any kind of national

statistics. 3. Use of a multitude of applications (Microsoft Excel for the hazard register, written documents

to report the occurrences, Word for the reports of the Safety meetings, PowerPoint for the presentations,

etc.), leading to a very diffuse SMS within each organization.

In an effort to standardize and cover the full scope of SMS in one interface, among BCAA Approved ATO,

BCAA has commissioned the development of SIA (SMS Interface for ATO). We hope this may be a useful tool

for all its users and are looking forward to your feedback and suggestions for improvement!

Many safe and happy landings in 2017!

Jelle Vanderhaeghe

Safety Coordinator BCAA Licensing Directorate


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0.7. Abbreviations:

ATO:

EASA Approved Training Organization, in accordance with EU 1178/2011

and EU 290/2012 (and their amendments), PART-ORA.ATO.GEN: Any

organization providing training for pilot licenses and associated ratings and

certificates.

EASA

European Aviation Safety Agency, a European institute responsible for

European civil aviation. www.easa.europa.eu

ICAO

International Civil Aviation Organization, a specialized United Nations

Agency, responsible for civil aviation. www.icao.int

SIA:

SMS Interface for ATO. The composition was commissioned by BCAA and

is freely offered to all Belgian/European (and if useful for) Third Country

ATO (Approved Training Organizations).

SMS:

Safety Management System. Legal requirement for all organizations active

in civil aviation, of ICAO Member States, since 2012, in accordance with

ICAO ANNEX 18 (SMS/SSP)


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INTENTIONALLY LEFT BLANK


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CHAPTER 1: Legal basis

1.1. EASA ORA.200 GEN - MANAGEMENT SYSTEM

(a) The organization shall establish, implement and maintain a management system that includes:

(3) the identification of aviation safety hazards entailed by the activities of the organization, their

evaluation and the management of associated risks, including taking actions to mitigate the risk and

verify their effectiveness;

(b) The management system shall correspond to the size of the organization and the nature and complexity

of its activities, taking into account the hazards and associated risks inherent in these activities.

AMC1 ORA.GEN.200(a)(1);(2);(3);(5) Management system

NON-COMPLEX ORGANISATIONS - GENERAL

(a) Safety risk management may be performed using hazard checklists or similar risk management tools

or processes, which are integrated into the activities of the organization.

(b) The organization should manage safety risks related to a change. The management of change should

be a documented process to identify external and internal change that may have an adverse effect on

safety. It should make use of the organization’s existing hazard identification, risk assessment and

mitigation processes.


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CHAPTER 2: GENERAL CONDITIONS:

SIA (SMS Interface for ATO) is a BCAA commissioned open source Microsoft Excel tool, destined for

practical, daily Safety Management, within EASA ATO.

BCAA holds the copyright of SIA and the Interface has been registered with the Belgian Patent

Bureau (DIE – Dienst voor Intellectuele Eigendom / OPRI – Office belge de Propriété Intellectuelle),

part of the Belgian Federal Public Service Economy.

SIA is made available FREE OF CHARGE to the whole aviation community, for the benefit of aviation

safety. All ATO worldwide are allowed to use SIA and provide BCAA with suggestions for

improvement. All companies or persons, Belgian or foreign, who use SIA and its contents to charge

money for it to third parties, will be prosecuted by BCAA for copyright infringement.

SIA is not to be modified by its individual Belgian users: it will be used for comparison purposes and

drawing statistics on a National level (and contribute to the European level), after de-identification

of the data. Modifications by individual users will render the statistics unusable, so individual

modifications and individual creativity should be avoided. Multiple cells are password protected and

not to be modified. Users are requested not to (try to) bypass the password protected cells.

Use of SIA is not legally obliged. BCAA approved ATO are strongly recommended to use SIA for

standardization among ATO and ease of oversight/comparison/exchange of safety data. ATO who

chose not to implement and use SIA, should demonstrate equivalent capabilities of their own

interface, at their own expense and responsibility, however.

With the implementation of SIA, ATO are estimated to be compliant with the implementation phase

of SMS. The proper use (follow-up of hazards and occurrences) is the sole responsibility of the ATO.

BCAA accepts no responsibility for accidents/incidents/occurrences, or findings of non-conformity

against national, European, or International (aviation) legislation, while using SIA.


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CHAPTER 3: CONCEPT:

3.1. Different TAB’s:

SIA is destined to cover the full scope of SMS (status of International and EU-legislation anno 2017)

for civil aviation, in accordance with EU 1178/2011 and its updates, in 1 Excel-sheet (© Microsoft),

distributed over 11 numbered TABs:

1. Annual Risk Assessment (TAB 1), or “Hazard Register”: to be assessed by each ATO, considering

their own particular situation (airfield, management, history, type of training and aircraft, etc.)

and reviewed 1x per year, in the light of reported occurrences, the year before.

2. Risk Assessment Matrix (TAB 2) - FOR INFO ONLY: Overview of the “Probability of occurrence”

vs “Severity of the outcome” (for info/clarification to the user), detailing the criteria by which

TAB 1 (the Annual Risk Assessment) is composed and the assessment of Risks/hazards should

be performed by the Safety Meeting.

3. Occurrence Follow-up 2016 (TAB 3): Each occurrence is to be encoded in TAB 3 in SIA, in a

standardized fashion, by the Safety Manager of the ATO. Follow-up must be performed within

the same TAB, on the same line, from the initial reporting of the occurrence, until mitigating

measures have been decided upon and implemented (to reduce the probability of the

occurrence and/or severity of the outcome, or to reduce the risk of reoccurrence). This TAB

may also be used as the report (minutes of meeting) of the ATO safety meeting(s) and also

serves as follow-up sheet for the Safety actions decided upon.

4. Occurrence Identification (TAB 4) - FOR INFO ONLY: Overview of all occurrences estimated

relevant for ATO and their “identifiers”, as applied in the European occurrence database

ECCAIRS.

5. Occurrence Classification (TAB 5) – FOR INFO ONLY: In TAB3 the Safety Manager, or the Safety

Meeting is requested to quantify the reported occurrence on a severity scale, ranging between

“Insignificant” and “catastrophic”

6. Visual representation (TAB 6) - FOR INFO ONLY: Automatically generated visual representation

of a preselected set of parameter as introduced the Occurrence Follow-up sheet (TAB 3), for

Management & feedback purposes, to visually represent the Safety statistics of the ATO.

7. Safety Plan 2018 (TAB 7): Based on the analysis of the occurrences in the preceding year (2017),

the ATO Safety Manager and Safety Meeting should compose a safety plan for the next year

(2018). An update/overhaul of SIA for 2018 is planned, so no plans are yet included for beyond

2018.


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8. Safety briefings performed (TAB 7): Depending on the Safety plan 2017 composed by the ATO

(as discussed above in item 5), BCAA would like the Safety Manager to keep track of the actual

safety briefings/lessons/Safety promotions performed within the ATO, in from 2017 onward.

9. Management of Change (TAB 8): Every major change in the ATO, may negatively impact safety

of the training activities and operations. A risk analysis of the new aspects introduced in the

ATO should be performed by the Safety Manager and/or Safety Meeting of the ATO and

documented in SIA, together with the risk mitigating measures (if necessary) taken by the ATO.

10. MOC (TAB 9) - FOR INFO ONLY: Overview of the “Complexity of change” vs “Impact of change”

(for info/clarification to the user) matrix, as a visual aid to assess changes to the ATO.

11. NCO Checklist for Introductory Flights: The Safety Manager, or his deputy is present during

Introductory Flights, can use the checklist provided as a guideline for safe conduct of the

promotional events for pilot training.


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3.2. BCAA requirements in the use of SIA:

All BCAA approved ATO are requested to organize at least 2 SAFETY MEETINGS PER YEAR. All BCAA

approved RF (future DTO)* are requested to organize at least 1 SAFETY MEETING PER YEAR. A

reasonable spread should be maintained over the course of the year (3 consecutive meeting in 3

days is useless). Additional “Ad hoc” meetings should be organized when reality so requires.

Examples: Occurrence/accident/incident related to the ATO/DTO that requires urgent action,

significant change(s) to the ATO, environmental, international or legislative changes, etc. Additional

Safety meetings may/should be assembled at the request of any post holder of the ATO (not just

the Accountable Manager, or Safety Manager), but may also be combined with other meetings

within the ATO/DTO.

SIA can serve both as a planning tool (agenda), as well as a reporting tool (minutes of meeting) for

the ATO Safety Meetings. The ATO should keep 1 copy of SIA as a “Master working document” to

keep track of evolution and follow-up of occurrences, and the safety actions decided upon within

the ATO. Regular back-ups are recommended to avoid data-loss.

Failure to produce any SIA filled in properly within the ATO (when there is no other SMS in use), will

not be accepted under any pretense (the “sadly, we lost all files yesterday”-factor) and will

automatically lead to a level 1 finding, requiring immediate corrective action, or immediate

suspension of the ATO/DTO training activities. Therefore it is up to the ATO/Safety Manager to

assure sufficient electronic back-ups, or printed versions of SIA (BCAA prefers paperless, soft copies,

to reduce the eco-footprint).

* RF = JAR-FCL “Registered Facility”, or flight club, providing training for PPL and additional ratings. Under the current

status of European Air Crew Regulations, will become “DTO” (or Declared Training Organization, as replacement for BTO,

or Basic Training Organization, as planned by EASA NPA 2015-20, intended to replace the original non-complex ATO).

The applicable European Notice for Proposed Amendment (NPA 2015-020) regarding EASA DTO (Declared Training

Organizations) is expected to be voted and approved over the course of 2016. BCAA wishes to anticipate to this

impending administrative simplification of requirements for organizations previously designated “BTO” (Basic Training

Organization) and prior as “non-complex ATO”.


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CHAPTER 4: Getting started with SIA:

Please save the initial empty SIA on your computer (or preferably ATO server, or other virtual

environment) and perform regular back-ups of the filled in SIA, to avoid data loss.

ATO should keep 1 filled-in copy of SIA as a “Master working document” per year, but updated

regularly, related to the mandatory internal Safety Meetings. Starting as of January 1st 2017, BCAA

requests to adhere to the following reference, to save the “Master working document” of SIA within

the ATO:

BE-ATO-XXX_SIA_31-12-2017.xls (xxx is the ATO approval reference)

The above date is indicative as the date to close off the first year of working with SIA.

ATO are requested to forward the SIA “Master Working Document” to [email protected]

for audit purposes and drawing statistics, on a national level. This for the purpose only of identifying

true safety issues (demonstrated objectively from the SIA from all participating ATO).

4.1. STEP 1: Annual Risk Assessment:

Step 1 in the start-up of an SMS within your ATO, is a Risk Assessment of the actual situation (or

projected situation if the organization is starting up) in the case of an existing ATO, or converting

JAR-FCL RF/FTO/TRTO. BCAA has summed-up 150+ safety hazards threatening today’s civil aviation

training. The first step in safety management is a self-assessment via brainstorming by the

participants to the first Safety Meeting of the ATO (“Kick off”), of the current/projected situation of

risks, via the assessment of the estimated PROBABILITY and SEVERITY of each of the risks.

BCAA is aware this first step in SMS is a SUBJECTIVE PROCESS (not 100% accurate image of the actual/existing ATO

situation), but the kick-off is unavoidably based on personal feeling and experience, of those active in the ATO. It is a first

attempt at rendering the hazards threatening the ATO more objective. The Risk assessment should be reevaluated

annually (once per year), based on the occurrence follow-up and will inherently become more objective and quantified

over time.

Each hazard should be assessed for the ATO individually, but comparing its own situation, on a Belgian/European scale.

Example: the airport of Ostend (EBOS) is located next to the North Sea. The terrain is flat and there are hardly any

obstacles in the vicinity, so the risk of CFIT (Controlled Flight Into Terrain) is lower, compared to the airfield of Saint-

Hubert (EBSH) located in the hills of the Belgian Ardennes and much lower than extreme airports like the altiport of

Courchevelle (LFLJ)


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4.2. STEP 2: Follow-up of occurrences:

The Safety Manager of the ATO should keep track of all the Safety Occurrences reported within the

ATO, in TAB 3, “Occurrence Follow-up sheet 2017” (FYI: The first major analysis of the effectiveness

and overhaul of SIA is planned for end 2017, SIA version 2.0 can be expected and will be forwarded

for implementation by all BCAA ATO, as of January 1st, 2018. This may also lead to an online

platform, but is not yet guaranteed at this stage).

Per reported occurrence, the ATO Safety Manager (or his/her deputy) should:

1. Register a newly reported occurrence in a new TAB 3 of SIA, and summarize the relevant

details of the occurrence

2. Perform an RISK IDENTIFICATION of the occurrence (drop down menu in column H of TAB

3), based on the list of European occurrences (the overview can be found in TAB 2)

3. Perform a RISK CLASSIFICATION of the occurrence (Insignificant -> Major), (the overview can

be found in TAB 5).

4. Indicate the MAIN CAUSE of the OCCURRENCE

5. Select 1 (or more, with a maximum of 2) CONTRIBUTORY FACTORS

6. Perform a ROOT CAUSE ANALYSIS of the occurrence:

7. Perform an assessment if the occurrence needs FOLLOW-UP (if “NO, the occurrence may be

closed, if “YES” the occurrence must be debated during the Safety Meeting).

8. Perform an assessment if the occurrence should be reported to the authorities, in

accordance with the items listed in EU 1018/2015, “Mandatory Occurrence Reporting”.

4.3. STEP 3: Safety Meeting:

The Safety Manager (or Accountable Manager) of the ATO should organize at least the minimal

amount of required annual Safety meetings (ATO: 2, BTO: 1) in a timely fashion and well in advance,

so all persons required can attend.

The agenda of a planned Safety meeting, is SIA TAB 3 with an overview of all the safety occurrences

in the ATO, of the recent past and the preliminary analysis of the occurrences, performed by the

Safety Manager.

The Safety meeting should perform an overview of all the Safety occurrences the Safety Manager

of the ATO indicated as requiring further follow-up (but the other occurrences may be addressed

equally, should any member of the Safety Meeting disagree with the initial assessment of the Safety

Manager). It should decide as a group on the course of action to prevent the occurrence from

happening again and set up a set of actions and allocate resources. Proposals made by the Safety

Manager that are rejected, should be motivated. A responsible Post Holder in the ATO must be

allocated for the actions agreed to by the Safety Meeting, in order to avoid reoccurrence and

elimination of safety hazards in the future.


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4.4. STEP 4: Follow-up:

The effectiveness of previous corrective actions and precautionary measures taken to prevent

reoccurrence, should be reevaluated (if possible) by the Safety meetings and a rerun of the risk

assessment should be performed. If reoccurrence is estimated sufficiently mitigated, the occurrence

may be closed. Occurrences that were not closed during a previous Safety meeting and that are still

not closed after re-evaluation, or cannot be closed by a consecutive Safety meeting, should be

marked in blue (“Long term solution”), and may be closed. This can be the case if the ATO has no

direct influence on the hazard, due to for example environmental, or legislative issues, or when a

significant investment of time and resources is required over a larger period of time. This however

requires proper motivation by the ATO Safety Manager, or Safety meeting.

SIA also serves the purpose as report of the Safety meeting (no other notes, or “minutes of meeting”

is required as proof the meetings were organized).

4.5. STEP 5: Safety planning:

The results generated by SIA for a particular ATO after one calendar year, should result in a Safety

plan for the next year (the results of SIA of 2016, should result in the Safety plan of 2017). The Safety

Manager, or the Safety meeting should distill out of the results kept in SIA TAB 7 listing 5 MAIN

HAZARDS, 5 TYPES OF OCCURRENCES AND 5 MAIN CAUSES OF OCCURRENCES, the ATO wishes to

address during in the following year. The Safety Manager, or meeting, may select from a number of

safety actions to focus on, during the next calendar year.

4.6. STEP 6: Safety briefing & promotion:

The Safety briefings performed in the light of the focal points, identified in STEP 5, may be kept track

of in the next tab (TAB 8 Safety briefings & promotion): The Safety Manager should keep track of all

the briefings and promo that was performed (by him/herself, instructors, post holders, or other

persons active in the ATO), to demonstrate there is a positive/continuous tendency towards and

focus on aviation safety within the ATO.

4.7. STEP 7: Management of Change:

A fully developed, mature ATO manages its own internal processes of compliance with the

applicable legislation and maintaining the highest standards of safety. One of the more recent

principles of running a safe operation is “Management of Change”: if there is a major change

implemented within the ATO, the Safety Manager should be asked to perform a risk analysis on the

extra hazards posed by the changes to the organization.


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This constitutes the following:

1. Description of the change

2. Listing the risks the changes proposed to the organization will/might generate

3. Performing a risk analysis on each of the identified risks

4. Mitigation of the risks identified

5. Execution of the change

6. Action plan and follow-up of the actions taken

7. Reassessment of the remnant risk, after risk assessment and implementation of the

remedial, risk mitigating actions

8. Final corrective actions

9. Closure of the change to the ATO, if successful, or return to the previous situation (before

the change was implemented), if the change to the ATO was estimated unsuccessful,

uneconomic, unsafe, not overall beneficiary, or other.

4.8. STEP 8: Use of SIA/SMS as a Management tool:

An ATO with a well-developed SMS and Safety culture, will use the results produced by SIA as a

Management tool, for the benefit of the ATO. An annual presentation to all those involved in the

ATO (leaflet, presentation, or other) is indicative of the maturity and overall acceptance of SMS as

a benefit for the ATO. Essential data for feedback is automatically generated by SIA, in TAB 6, VISUAL

REPRESENTATION.

Feedback to all participants of the ATO’s SMS (all who is reporting occurrences) is key to continuing

a “Reporting culture” within the ATO. It is strongly recommended that all involved in the ATO, would

receive feedback at least once a year (general, not addressed to individuals, or per sé occurrence-

specific) on the reported occurrences within the ATO (or other interesting cases outside the ATO)

and the outcome and initiatives and measures taken by the ATO to avoid reoccurrence.


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CHAPTER 5: Feedback of SIA to BCAA:

All feedback regarding SIA for improvement and optimization may be forwarded to

[email protected] It is requested that all users under BCAA supervision, would forward the

filled out (not disclosing any names of pilots/instructors/flight club members would be disclosed)

SIA in the above mentioned extension after 31/12/2017, for the purpose of auditing the ATO SMS

and generating statistics for the Belgian airspace.

Documents

BCAA Procedure Manual SMS INTERFACE for ATO (SIA) · BCAA Procedure Manual SMS INTERFACE for ATO ... the civil aviation industry adopted this, ... it will be used for comparison purposes