Doc 9859 Safety Management Manual Notice to Users This document is an unedited version of an ICAO publication and has not yet been approved in final form. As its content may still be supplemented, removed, or otherwise modified during the editing process, ICAO shall not be responsible whatsoever for any costs or liabilities incurred as a result of its use. Fourth Edition (advance unedited) — 2018 INTERNATIONAL CIVIL AVIATION ORGANIZATION ) \ Discover the ICAO Online Store Browse and shop here for ICAO's aviation products and services in all key areas of air transportation. SHOP ONLINE � icao.int/store ICAO \ Published in separate Arabic, Chinese, English, French, Russian and Spanish editions by the INTERNATIONAL CIVIL AVIATION ORGANIZATION 999 Boulevard Robert-Bourassa, Montréal, Quebec, Canada H3C 5H7 For ordering information and for a complete listing of sales agents and booksellers, please go to the ICAO website at www.icao.int. Advance edition (unedited) Doc 9859, Safety Management Manual (SMM) Order Number: 9859 ISBN 978-92-9249-214-4 © ICAO 2018 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, without prior permission in writing from the International Civil Aviation Organization. (iii) AMENDMENTS Amendments are announced in the supplements to the Products and Services Catalogue; the Catalogue and its supplements are available on the ICAO website at www.icao.int. The space below is provided to keep a record of such amendments. RECORD OF AMENDMENTS AND CORRIGENDA AMENDMENTS No. Date Entered by CORRIGENDA No. Date Entered by Find out how our digital publication can help you connect with your target audienceUnitingAviation.com provides custom marketing solutions to help you achieve your goals and reach high-level industry decision makers. Gain exposure on ICAO’s online platform and increase brand awareness, boost short term campaigns, generate new leads or launch a new product offering. UNITING AVIATIONREACH AVIATION DECISION MAKERS ONLINE (v) FOREWORD This fourth edition of the Safety Management Manual (SMM) supersedes the third edition, published in May 2013, in its entirety. The development of this edition was initiated after the adoption of Amendment 1 to Annex 19 to address the changes introduced by the amendment and to reflect the knowledge and experience gained since the last revision. To address the needs of the diverse aviation community implementing safety management and a recommendation stemming from the second High-level Safety Conference held in 2015, the Safety Management Implementation (SMI) website (https://www.icao.int/SMI) has been developed to complement the SMM and serves as a repository for the sharing of best practices. Practical examples, tools, and supporting educational material will be collected, reviewed and posted on the website on an ongoing basis. This edition is intended to support States in implementing effective State safety programmes (SSP). This includes ensuring that service providers implement safety management systems (SMS) in accordance with the provisions of Annex 19. In order to be consistent with safety management principles, a concerted effort has been made to focus on the intended outcome of each Standard and Recommended Practice (SARP), purposely avoiding being overly prescriptive. Emphasis has been placed on the importance of each organization tailoring the implementation of safety management to fit their specific environment. Note 1.— In this manual, the term “organization” is used to refer to both States and service providers. Note 2.— In this manual, the term “service provider” is used to refer to an aviation industry organization implementing SMS whether on a mandatory or voluntary basis, unlike Annex 19 which uses the term to refer to a very specific list of organizations found in Chapter 3, which excludes international general aviation operators. The fourth edition is divided into nine chapters which progressively build the reader’s understanding of safety management. These chapters can be grouped under the following three themes: 1) Safety management fundamentals – Chapters 1 to 3 build the reader’s understanding of the fundamental principles underpinning safety management. 2) Developing safety intelligence – Chapters 4 to 7 build on the fundamentals. These chapters comprise four interrelated topics concerned with leveraging safety data and safety information to develop actionable insights which can be used by an organization’s leadership to make data-driven decisions, including those related to the most effective and efficient use of resources. (vi) Safety Management Manual (SMM) 3) Safety management implementation – Chapters 8 and 9 explain how to apply the concepts from the preceding chapters to institutionalize safety management at the State and service provider level. Guidance to support sector-specific safety management SARPs found outside of Annex 19 (e.g. flight data analysis programmes) is not addressed in this manual. The Manual of Aircraft Accident and Incident Investigation (Doc 9756) contains guidance on the conduct of independent State accident and incident investigations in accordance with Annex 13 — Aircraft Accident and Incident Investigation. ICAO gratefully acknowledges the contributions of the Safety Management Panel (SMP) and the Safety Information Protection Implementation Group (SIP IG) as well as other expert groups and individual experts who provided support, advice and input for this manual. The content was developed over a period of two years and was thereafter submitted for an extensive peer review to collect and take into account comments from the expert community taking into consideration that the manual is expected to be the overarching guidance for safety management for a wide community. Comments on this manual, particularly with regard to its application and usefulness, would be appreciated from all States, safety oversight audit missions and ICAO technical cooperation field missions. These will be taken into consideration in the preparation of subsequent editions. Comments should be addressed to: The Secretary General International Civil Aviation Organization 999 Robert-Bourassa Boulevard Montréal, Québec H3C 5H7 Canada ______________________ (vii) TABLE OF CONTENTS Page Glossary ...................................................................................................................................................................(viii) Definitions ........................................................................................................................................................... (ix) Abbreviations and acronyms ............................................................................................................................ (xi) Publications .......................................................................................................................................................(xiii) Chapter 1. Introduction ............................................................................................................................................ 1-1 1.1 What is safety management? ......................................................................................................................... 1-1 1.2 Safety management applicability .................................................................................................................... 1-3 1.3 Implementing safety management .................................................................................................................. 1-5 1.4 Integrated risk management ........................................................................................................................... 1-7 Chapter 2. Safety management fundamentals....................................................................................................... 2-1 2.1 The concept of safety and its evolution .......................................................................................................... 2-1 2.2 Humans in the system .................................................................................................................................... 2-2 2.3 Accident causation ......................................................................................................................................... 2-5 2.4 Management dilemma .................................................................................................................................... 2-7 2.5 Safety risk management ................................................................................................................................. 2-8 Chapter 3. Safety culture ......................................................................................................................................... 3-1 3.1 Introduction ..................................................................................................................................................... 3-1 3.2 Safety culture and safety management .......................................................................................................... 3-1 3.3 Developing a positive safety culture ............................................................................................................... 3-3 Chapter 4. Safety performance management ........................................................................................................ 4-1 4.1 Introduction .................................................................................................................................................... 4-1 4.2 Safety objectives ............................................................................................................................................ 4-3 4.3 Safety performance indicators and targets ..................................................................................................... 4-4 4.4 Monitoring of safety performance ................................................................................................................. 4-11 4.5 Update of safety objectives .......................................................................................................................... 4-15 Chapter 5. Safety data collection and processing systems ................................................................................. 5-1 5.1 Introduction ..................................................................................................................................................... 5-1 5.2 Safety data and safety information collection ................................................................................................. 5-2 5.3 Taxonomies .................................................................................................................................................... 5-6 5.4 Safety data processing ................................................................................................................................... 5-8 5.5 Safety data and safety information management ........................................................................................... 5-9 Chapter 6. Safety analysis ....................................................................................................................................... 6-1 6.1 Introduction ..................................................................................................................................................... 6-1 6.2 Types of analysis ............................................................................................................................................ 6-2 6.3 Reporting of analysis results .......................................................................................................................... 6-4 6.4 Safety information sharing and exchange ...................................................................................................... 6-5 6.5 Data-driven decision-making .......................................................................................................................... 6-6 Next >