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CAMBRIDGE HELICOPTERS LTD T/A AEROMEGA HELICOPTERS
SMS MANUAL
PART-ORA
APPROVED
SAFETY MANAGEMENT SYSTEM MANUAL
This document supports the European Union
PART-ORA Approved Training Organisation Approval of:
Cambridge Helicopters Ltd T/A Aeromega Helicopters
Cambridge Airport,
Newmarket Road
Cambridge
CB5 8RX
Tel: 01223 294488
Fax: 01223 294499
e-mail: Cambridge@aeromega.com
PART-ORA APPROVAL
REFERENCE
GBR.ATO-0311
Document Reference No:
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Letter of Transmittal
Date: ……………………
For Manual /Amendment* Approval
Document Ref. No: ……
Original Issue*
Amendment Revision No.:* ……….
Ref.
[page no]
Remove
Insert
Brief Details of Amendment
Approved By:
Compliance Manager
Part-ORA Cambridge Helicopters Ltd t/a Aeromega Helicopters
Date:
* delete as required
--------------------------------------------------------------------------------------------------------------------------FOR UK CAA USE ONLY
Approved By:
For the UK Civil Aviation Authority:
Date:
Following investigation and approval by the UK CAA, a signed & stamped copy of this page shall be
returned to the Part-ORA Cambridge Helicopters Ltd t/a Aeromega Helicopters for inclusion in all
copies held by the company.
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Record of Amendments
Issue No
Date Issued
Incorporated by
1
31.12.13
Head of Training
2
10.06.14
Head of Training
Signature
Date Incorporated
3
4
5
FOREWORD
This manual has been prepared in order to support the Cambridge Helicopters Ltd trading as
Aeromega Helicopters herein after referred to as “the Company” PART-ORA Approved Training
Organisation Approval. The Company’s set of ATO manuals consist of FOUR parts, this Safety
Management System Manual forms Section 3* of the Organisation Management Manual which is
Part 1 but is maintained as a separate controlled document.
PART 1
ORGANISATION MANAGEMENT MANUAL
1) Management Procedures
2) Compliance Monitoring
3) Safety Management System*
PART 2
OPERATIONS MANUAL
PART 3
TRAINING MANUALS
Private Pilot’s Licence (H)
Commercial Pilot’s Licence (H) Modular (Flying only)
Flying Instructor (Restricted) Course
Type Rating Training Courses
PART 4
APPENDICES
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CIRCULATION AND DISTRIBUTION
This Manual is a Controlled Document and amendments must be adopted in accordance with the
procedure detailed in the Foreword of the Company Operations Manual Section entitled Document
Control and Amendment.
Copies to be distributed to the following parties:
1
2
3
4
Head of Training/Safety Manager/Accountable Manager/Office Copy
Compliance Manager
Civil Aviation Authority
Company Website (electronic copy)
This document is available to all personnel involved in the Company as a paper copy held in the
Company’s main office. An electronic copy is available on the Company website. Updates and
amendments will be advised through personal e-mail to Company personnel and via the website to
other stakeholders. Updates and amendments will be advised:
1. through personal e-mail to management personnel and any person required to follow its
procedures;
2.
through an electronic copy to the UK CAA
3. through a general e-mail to other stakeholders and information posted on the Company
website.
The following post holders will receive specific notice of amendments by e-mail:
Accountable Manager
Safety Manager
Head of Training
Compliance Manager
UK CAA
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Glossary of Terms
Accident
Undesired event giving rise to death, ill health, injury, damage or loss.
Audit
A systematic examination to determine whether activities and related
results conform to planned arrangements and that the arrangements
are implemented effectively and are suitable for achieving Company
safety policy and objectives.
Any change to the Standard Operating Procedures in the Operations
Manual.
Change of
procedure
Hazard
Source or situation with a potential for harm in terms of injury or ill
health, damage to property, to the environment, or a combination of
these.
Hazard
Identification
The Process of recognising that a hazard exists and defining its
characteristics.
Incident
An event that gave rise to an accident or had the potential to do so.
Likelihood
The estimated probability or frequency, in quantitative or qualitative
terms, of an occurrence related to the hazard.
Nonconformance
A deviation from work standards, practices, procedures, regulations,
management system performance etc. that could either directly or
indirectly lead to injury or illness, property damage, damage to the
environment or a combination of these.
Objectives
Goals, in terms of performance, that an organisation sets itself, to
achieve.
Safety
Management
System (SMS)
Part of the overall management system that facilitates the management
of the risks associated with the business of the organisation. This
includes organisational structure, planning activities, responsibilities,
practices, procedures, processes and resources for developing,
implementing, achieving, reviewing and maintaining the company’s
policy and objectives. It does NOT define safe practices, but monitors
implementation.
Severity
The consequence or impact in terms of degree of loss or harm.
Performance
Measurable results of the management system, related to the
company’s ability to control risk.
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Table of Contents
Section
Subject
Frontispiece
List of Effective Pages
Letter of Transmittal
Record of Amendments
Circulation and Distribution
Glossary of Terms
Table of Contents
1
Introduction
2
2.1
2.1.1
2.1.2
2.2.
2.2.1
2.2.2
2.2.3
2.3
2.4
Safety Policy & Objectives
Management Commitment & Responsibility
Scope of Manual
Company Safety Policy
Safety Accountabilities
Safety Manager/Accountable Manager
Safety Committee
Flying Instructors
Appointment of Key Staff Members
SMS Documentation
3
3.1
3.2
3.3
3.3.1
3.3.2
3.3.3
3.3.4
3.3.5
3.3.5.1
Safety Risk Management
Hazard Identification
Reporting System
Risk Assessment and Mitigation
Risk Severity
Risk Likelihood
Risk Tolerability (including matrix)
Risk Mitigation
Hazard Log
Example Hazard Log
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
Safety Assurance
Safety Performance & Measurement
Safety Performance Indicators (SPI’s)
Safety Data
Management of Change
Incident Management & Investigation
Emergency Response Plan
Continuous Improvement
Audits
Reviews
Contracted Activities
Safety Management
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4.12
4.13
4.14
4.15
4.16
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
1
SMS MANUAL
Compliance Monitoring
Safety Promotion
Training & Education
Safety Communication
SMS Documentation Suitability
Appendices
Safety Committee Standard Agenda
Emergency Response Plan (ERP)
Example Incident Log
Staff Training Records
Risk Assessment Procedure for Change of Process
Hazard Log Entry Listing
Safety Report & Hazard Log Form
Roles and Responsibilities
Safety Performance Indicator Matrix
Introduction
As an Authorised Training Organisation, Cambridge Helicopters Ltd t/a Aeromega Helicopters (the
Company”) is required to operate a Safety Management System (“SMS”). The development of an
SMS is on-going and the operation of the system is detailed in this manual (”the SMS Manual”).
The Company will continually monitor its current, future and third party safety risks and will take
action to address unacceptable safety risks. It seeks to uphold a “Just Culture” encouraging all parties
to participate in raising safety issues without fear of reprisal or unjustified disciplinary action (illegal
or negligent acts and wilful misconduct precluded).
Management is to ensure that staff at all levels are made aware of, and understand, their
accountabilities, authorities and responsibilities regarding Safety Management processes, decisions
and actions.
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2
Safety Policy & Objectives
2.1
Management Commitment & Responsibility
SMS MANUAL
2.1.1 Scope of the Manual
This Safety Management System Manual is a reference document describing how safety is
managed in and:
(a) is the key instrument for communicating the Company’s approach to safety to all its
personnel;
(b) documents all aspects of safety management, including the safety policy, objectives,
procedures and individual safety responsibilities;
(c) will be distributed throughout the Company to ensure that all personnel are fully aware
of the system, thereby ensuring:
i. That safety is a central component in our management system;
ii. That safety is accounted for in all decisions and actions taken by all in the
Company;
iii. The needs, requirements and expectations of customers and other parties are
fulfilled.
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Company Safety Policy
2.1.2
Safe flight training is our principal objective. We aim to deliver the flight training required by each
syllabus in a safe and controlled manner. Our intention is to produce good pilots rather than just
people who know how to fly a helicopter. The Safety Policy is applicable to all stakeholders e.g.
customers, suppliers, subcontractors as well as employees.
We promote good airmanship and encourage the consideration of safety matters throughout our
flying community.
As the Accountable Manager, it is my responsibility to ensure the safety of all flying sorties and
other operations.
Adequate human and financial resources will be made available to manage, communicate and
implement safety policy effectively.
We encourage all our staff and customers to report safety events or potential hazards however
insignificant they may consider them at the time.
We have an open reporting culture that encourages free and frank reporting through a just culture.
Our aim is that we will strive to achieve:





an accident free environment.
an effective safety management system and continuous improvement towards the highest
possible safety standards.
compliance with the statutory national and international regulations that apply to our
operation.
a commitment to reduce risks to as low as reasonably practicable.
observe best practice as appropriate for a small non-complex flying school.
We undertake to communicate changes in Safety Policy to all customers, instructors, examiners
pilots and staff. This will be principally achieved through e-mail and by publication on the website.
These objectives are for the benefit of the company, its employees and its customers. To this end we
have a shared responsibility to achieve these aims. All stakeholders are to be familiar with the Safety
policy and should be committed to its observance.
Safety and good Airmanship is the primary responsibility of all and is for the benefit of all.
This policy is wholly endorsed by the Board of Directors and the Company’s owners and the
Company is fully committed to achieve the aim stated above.
All stakeholders should have trust and confidence in the Company’s reporting procedure and its justculture.
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I confirm that I understand the Safety Management responsibilities and accountabilities which I am
required to observe/undertake/comply with and the necessary processes, decisions and actions which
are to be implemented.
Signed by Accountable Manager
Signed:
…………………………………………………………………………….
Capt. Duncan Bickley – Accountable Manager
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2.2
Safety Accountabilities
2.2.1
Accountable Manager/Safety Manager
Given the small size of the Company, the roles of Safety Manager and Accountable Manager
are combined. The Company Accountable Manager (AM) is ultimately accountable for safety
in the Company and has day to day responsibility for the safe operation of the flying school,
the operation of the Safety Management System and the promotion of safety within the
organization. The AM will have budgetary authority to implement any safety measures
which are deemed necessary to achieve the Company’s safety objectives.
The AM will also nominate a Compliance Monitoring Manager and appoint the members of
the Safety Committee.
2.2.2
Safety Committee
The Safety Committee is comprised of the Safety Manager and Staff Instructors.
The committee will meet following any significant safety event and shall comprise of the
following mandatory attendees:
The Safety Manager,
One Staff Instructor representing all others.
In any event the Safety Committee shall meet at least annually with not more than 12 months
between meetings and will follow the standard agenda detailed in Appendix 1.
Minutes are to be taken and retained by the Safety Manager for a period of at least 5 years.
2.2.3
Flying Instructors
The Staff Instructors are key members of the Safety Management process and are responsible
for raising any identified risks with the Accountable Manager immediately they arise – using
the specified format.
2.3
Appointment of Key Staff Members
The organizational structure is as follows:
Group Board
Accountable Manager }
Safety Manager
} Capt. Duncan Bickley
Head of Training }
Staff Instructors
Capt. Ian Mills
Operations Staff
Chelsea Mayes
Weekend/Temporary Staff
Compliance Monitoring Manager
Mr William Tobin
The specific responsibilities of each role are detailed in Appendix 8.
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2.4
SMS MANUAL
Documentation
This Safety Management System (SMS) Manual is part of the Company’s ATO
documentation. A description of the full set of ATO manuals can be found in the Company
Operations Manual. This SMS manual is maintained as a controlled document in accordance
with the procedure detailed in the Company Operations Manual.
All SMS records, hazard log entries, risk assessments, safety reports and safety cases are to
be maintained in the formats prescribed in the Appendices by the Safety Manager and stored
in the SMS Folder for a minimum of 5 years from the date of generation.
3.
Safety Risk Management
The safety risk management process commences with the identifying of hazards, assessing
the risk and likelihood and severity of their occurrence. Once a measurable value has been
placed on such a hazard, it is the Safety Committee’s responsibility to identify appropriate
remedial action or mitigation measures which when implemented will reduce the risk to as
low as reasonably practical. The Safety Committee must then monitor and ensure such
measures are subsequently implemented and review their effectiveness.
3.1
Hazard Identification
A Hazard is a condition , event or circumstance that has the potential to cause harm to people
or damage helicopters, equipment or structures.
A Risk is the potential outcome from a Hazard and may be defined in terms of likelihood
and severity.
Hazard Identification is an on-going process co-ordinated by the Safety Manager and relies
on discussing any new procedures, ideas or proposals for operations and considering the
hazards and risks involved. By definition, it is an ad hoc process which requires continuous
awareness. Given the small size of the organization and the close working relationship
between the team, it is relatively straight forward to ensure that this process is on-going.
However regular Safety Management Committee “brainstorming sessions” will be arranged
to identify any other area of potential risk.
An initial hazard log has already been produced based on previous incidents and potential
hazards. This will be developed with time.
The Safety Manager will obtain and display safety report publications such as GASIL and
Safety Sense leaflets on the Company notice boards. Any incidents reported which may be of
particular relevance to the Company will be raised through the system for consideration by
the Safety Committee.
3.2
Reporting System:
3.2.1 Should any incident occur or a risk identified, all staff and customers are to be encouraged to
send a free format email immediately to the Safety Manager (c.c. other Committee
members) stating the issue. It must contain the date and time of the incident where
appropriate. Whilst the report should be de-personalised, it is in reality extremely difficult to
conceal identities in such a small organization.
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3.2.2 Any occurrence that an individual feels could have led to, or actually did lead to, a
compromising of safety should be reported. This includes Human Performance
related hazards. Whilst it is easy to think that the consequences of a particular
occurrence are/were negligible, these “almost incidents” or “near misses” (not to be
confused with Air Prox*) need to be reported so that we can build up data and identify
trends. E.g. A bird scaring vehicle moving across a take-off run may be avoided by a
good margin but the practice creates a hazard and needs to be recorded, assessed and
mitigated to protect us in the future.
* An Air Prox is a report filed with the Authorities when two or more aircraft
have been in close proximity to one another to the extent that either commander
believes a collision hazard existed.
3.2.3 On receipt of such an email, the Safety Manager will raise a combined Safety Report
& Hazard Log Form as contained in Appendix 7 and will “take ownership” of the
report and arrange a time for an ad-hoc Safety Committee meeting for a discussion of
the incident. At such meeting, risk will be quantified and measures agreed to
manage/mitigate the risk to As Low As Reasonably Possible (“ALARP”). The Safety
report Form & Hazard Log Form will be updated accordingly by the Safety Manager.
3.2.4 Responsibilities for actions agreed will be recorded on the Safety Reporting and
Hazard Log form and diarised to ensure execution by the Safety Manager. This may
include additional reporting processes such as raising an MOR, Airprox etc. and
involve communicating with other organizations e.g. the Airport or Flying Clubs as
appropriate.
3.2.5 If it is not possible to manage/mitigate the risk down to a reasonable level, then the
activity will be discontinued or prevented from being repeated. The hazards identified
do not have to have already occurred, it fact it is best to be pre-emptive and identify
hazards and risks before they arise.
3.2.6 At the annual Safety Committee Meeting, all the Hazard Logs raised during the
previous period will be reviewed and an assessment of how successful the mitigation
measures applied have been in assuaging the risks.
3.2.7 Staff and customers are encouraged to report all potential hazards and may choose to
do so anonymously by writing to the Safety Manager. This will allow confidential
reporting that enables the Company to deal with the matter in a just and equitable
manner. It is not the intention to punish reporters for errors or lapses, merely to
identify hazards, prevent recurrence and ensure that lessons are learned. Whilst the
Company operates a “Just Culture” and actively encourages reporting of incidents, it
will not overlook illegal or negligent acts or cases of wilful misconduct which will be
deemed to be unacceptable behaviour.
3.2.8 Staff are encouraged to be dispassionate and raise any hazard, even where it may
involve management or post holders. Such persons must adopt a detached and
objective view of the report and should make particular efforts not to be defensive or
dismissive of reports involving themselves.
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3.2.9 The Safety Committee will consider how any organizational changes may affect
operations and whether any new hazards arise from such changes. This is specifically
included in the standard agenda for the Safety Management Committee meetings.
3.2.10 Any information regarding Safety and requiring dissemination will be achieved as
specified in Section 4.15 Safety Communication below.
3.2.11 The Safety Committee will continually monitor safety performance and SMS
effectiveness reviewed at the annual Safety Committee Meeting agenda.
3.3
Risk Assessment & Mitigation
The purpose of risk assessment to allow the Company to quantify the risk associated
with any identified hazard in terms of severity and likelihood using a risk assessment
matrix to assign a risk value. The Company will then consider whether this is
acceptable and identify measures to reduce this risk value where it is not acceptable.
Mitigation measures can reduce either likelihood or severity of an identified hazard to
bring the risk value within the acceptable range. By assigning a value, the Company
is able to prioritise the hazards with the highest risk value. The risk assessment
process is as follows:Identify hazard and associated risk
Evaluate severity of consequences
Evaluate likelihood of occurrence and consequences
Calculate the risk value
Evaluate the Risk Tolerability per the matrix
Risk Tolerability
Acceptable
Risk Tolerability
Not Acceptable
Avoid or mitigate risk to acceptable level
Safety Monitoring to ensure mitigation measures effective
3.3.1
Risk Severity
Risk Severity is designated as follows:-
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Category
Example
1
2
3
4
5
Breach of Operation manual minima
Impact on Reputation / Environment / Insurers
Injury of crew / Damage to aircraft
Serious Injury of those on board or major damage of aircraft
Deaths / Injuries of by-standers, destruction of aircraft
Negligible
Minor
Major
Hazardous
Catastrophic
Flying, by definition can be hazardous and many incidents could be deemed to have a
severity of Catastrophic and it is fairly unlikely that the Severity score can be reduced, in
which case the mitigation measures must seek to reduce the probability. Risks will need to be
assessed for severity (how bad will it be?) To assess severity, the worst possible realistic
scenario any existing mitigation factors must be considered first and then Severity should be
adapted for the most creditable outcome. The following factors are to be considered:
Loss of life: employees, customers, public etc
Likely extent of damage to property or financial damage?
Likelihood of environmental impact (spillage/habitat destruction)
Commercial implications
Media interest
Loss of reputation.
3.3.2
Risk Likelihood is designated as follows:
1
2
3
4
5
3.3.3
Category
Extremely Improbable
Improbable
Remote
Occasional
Frequent
Example
Possible but unknown in similar operations;
Documented as having occurred somewhere;
Has not previously occurred at Company;
Has previously occurred more than once somewhere;
Is a common occurrence in similar operations.
Risk Tolerability
Risk Tolerability is calculated by multiplying the Risk Severity by the Risk Tolerability; the
higher the number the greater the priority is for dealing with the hazard. E.g. a Catastrophic
Severity of 5 with a Probability of Remote 3 produces a score of 5 * 3 = 15.
The Risk Tolerability Matrix to be applied is as follows:RISK
RISK SEVERITY
PROBABILITY 5 Catastrophic 4 Hazardous
3 Major
Frequent
Unacceptable Unacceptable Unacceptable
5
Occasional
Unacceptable Unacceptable Review
4
Remote
Unacceptable Review
Review
3
Improbable
Review
Review
Acceptable
2
Very Improbable Review
Acceptable
Acceptable
1
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2 Minor
Review
1 Negligible
Review
Review
Acceptable
Acceptable Acceptable
Acceptable Acceptable
Acceptable Acceptable
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Definitions
Unacceptable
Scores of 15 or above - Activity is too risky and should cease
Review
Scores of 7 to 14 - Mitigation measures have been adopted and the score
is in the Review section of the matrix. The mitigation is considered to have
reduced the risk to ALARP but for example, the cost of further
mitigation prohibitive or the activity is mandatory and cannot be carried
out without a degree of higher risk than normal e.g. Engine Off Landings
etc. The Company may continue with the activity but will continue to
review mitigation measures at least annually to identify if further
measures can be introduced. The risk may be accepted, provided that it is
understood and has the endorsement of the Accountable Manager
Acceptable
Scores of 6 or under - Risk acceptable, further review is unnecessary
3.3.4
Risk Mitigation
If the level of risk is Unacceptable, further mitigation measures need to be established to
reduce the risk to ALARP.
Risk mitigation falls basically into 3 categories: Avoid, Reduce or Segregate.
Avoid: Cease the activity altogether;
Reduce:
Reduce the number of occasions when the activity is performed;
Segregate:
Specify additional limitations or procedures to mitigate risk factors
When measures are implemented to mitigate severity/likelihood, a further assessment of
tolerability will be conducted using the matrix above.
3.3.5 Hazard Log
3.3.5.1 A Hazard Log is to be produced by the Safety Manager recording each and every matter
raised by the SMS process. This includes any predicted hazards and will be developed in
response to newly perceived hazards and incidents reported. The Hazard Log contains detail
of the hazard identified and its calculated risk tolerability given any mitigation measures
already in place. It can then be used to record the resultant tolerability and the further
measures proposed to mitigate risk further and assess whether the additional measures have
achieved the desired outcome. A list of the Hazard Log Entries is contained in Appendix 6.
3.3.5.2 Due to the size of the organization and in the interests of simplicity, we have combined the
Safety Reporting Form with the Hazard log form. The same form can therefore be used to
track progress and ensure implementation is achieved. An example of the Safety report /
Hazard Log form is laid out below for reference. The form can be extended as necessary to
contain all adequate detail and revisions over time.
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4
Safety Assurance
4.1
4.1.1
Safety Performance Monitoring & Measurement
By monitoring the effectiveness of the SMS, the Management can gain confidence that the
process is effective and that mitigation measures are identified and more importantly being
successfully implemented to have the desired effect.
4.2
Safety Performance Indicators (SPI’s)
To assess performance, the Company will use key SPI’s. The recommended “Significant
Seven” which are the categories of incidents which most often lead to significant safety
breaches and for which Safety Performance Indicators are specified are as follows:Loss of Control
Runway Incursion
Runway Excursion*
Airborne Conflict
Controlled Flight into Terrain
Ground Handling
Fire
Not all these are appropriate to Company operations and fleet, therefore we do not propose to
concern ourselves with those denoted * and have identified our own more appropriate
categories.
The Company has defined its key Safety Performance Indicator targets which are specified in
the table in Appendix 9. Such an updated table will be prepared by the Safety Manager for
review at each annual Safety Committee meeting and identify any trends. Any such trends
identified will be minuted together with the Committee’s recommended course of action to
reverse them. Each Safety Committee meeting will assess the effectiveness of the
recommendations of any previous review.
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4.3
SMS MANUAL
Safety Data
To assist in the performance management process, safety data may be gathered from:
 Hazard and incident reports
 Warranty claims and customer complaints
 Mandatory Occurrence Reports
 Birdstrike Reports
 Customer/contractor surveys
 Safety surveys and audit findings
 AAIB/NTSB reports
 Compliance inspections
4.4
Management of Change
4.4.1 The Safety Committee should be called upon to meet, whenever a significant change in the
Company structure, operations or equipment or key personnel takes place. It will then take a
wide ranging review of the effect of such changes and identify any new hazards or changes to
existing risk measures that may result.
4.4.2 At each regular Safety Committee meeting, the impact of any operational changes which have
occurred since the previous meeting must be assessed in case any have slipped through the
net.
4.4.3 Risk Assessments are to be carried out in respect of the financial and commercial
implications when, for example, changing suppliers. The Company shall implement a
structured process (see Appendix 5) to identify and quantify such hazards in terms of
severity and propose mitigations of the potential risks of such changes. All appropriate
stakeholders are to be included in the process and the findings of such Risk Assessments must
then be presented to the Board for sanction before the adoption of any such change.
4.5
Incident Management & Investigation
4.5.1 Following a significant incident or accident, where a Safety Report form has been raised the
Safety Manager will conduct an investigation. Such investigations are mandatory where there
has been a fatality, injury or the helicopter requires out of phase engineering inspection.
However at the discretion of the Safety Manager, an investigation may be undertaken for any
incident. A chief objective of such safety investigations shall be to determine the root cause.
4.5.2 The Safety Manager will employ such resources as are required to ensure that the entire
incident is fully investigated. This may be in conjunction with, or independent of any other
investigation being carried out by the authorities. Such an SMS investigation should involve
all parties concerned and should be targeted at understanding the cause and future prevention
of similar incidents. The Safety Manager must ensure that the findings of any such
investigation are fed back to the Safety Committee and that Hazard Log entries raised are
processed in accordance with the procedures contained herein.
4.5.3 The Safety Manager must maintain an unbiased and objective role in such investigations and
should consider whether any conflict of interest exists which may interfere with the process.
If it is felt that such a conflict exists, then a board member will nominated to conduct the
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investigation in the Safety Manager’s place. At all times the investigating parties must
observe the Company’s stated “Just Culture” and avoid a punitive demeanour.
4.5.4 Such investigations shall include interviews and the collection of written statements from all
parties. Analysis of the factors contributing to the event, identification of possible “chainbreak” moments whereby the event could have been avoided, CRM factors and weaknesses
in procedures. The principal objective is to formulate new practices and procedures which
prevent repetition of the event, however an additional objective is to identify any other
common practices which may hold similar risks.
4.5.5
Incident Investigation Procedure/Process to be as follows:Safety Report and Hazard form raised for significant incident;
Safety Committee Meeting date arranged ;
Investigation conducted to gather data;
Root Cause established;
Conclusions presented to Safety Committee meeting;
Further Hazard Log entries arising from investigation raised;
Findings communicated to rest of organisation as specified in section 4.15 below.
4.6
Emergency Response Plan
4.6.1 The Company is required to have an Emergency Response Plan (ERP) which is to be
activated immediately in the event that any helicopter is involved in an incident or accident.
A copy of the step-by step Accident Reporting Procedure to be followed is contained in
Appendix 2 of this manual and is also accessible via the company website. A laminated copy
of this ERP and the Accident Reporting Procedure is to be displayed in Ops and the
Head of Training’s Office.
4.6.2 Immediately upon the Company being advised of such an incident, the recipient of such
information shall immediately take preliminary charge of the situation as the designated
initial Emergency Authority (EA) and will immediately advise the most experienced
instructor on duty who will take over as EA. In the event that the most experienced instructor
on duty is flying they shall be instructed to return to base immediately whereupon they will
assume the role of EA.
4.6.3 Where the EA considers appropriate to curtail any other Company flying activity, they will
contact Air Traffic and pass a brief to all other fleet aircraft to that effect.
4.6.4 The EA will be responsible for ensuring that the Accident Reporting Procedure as detailed in
Appendix 2 is put into operation immediately.
4.6.5 Once contacted, Senior Management will liaise and appoint one of their number to take over
the EA responsibilities and control of the incident.
4.6.6 Prior to returning to normal operations, the EA will ensure that the Accident Reporting
Procedure has been completed.
4.6.7 In the event that next of kin need to be informed, the EA is to liaise with the Police before
doing so.
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4.6.8 Responses to enquiries should be limited to those detailed in the ERP.
Do not contact or disclose any details to next of kin until specifically authorised.
Do not post comment on Social Media Sites e.g. Facebook, PPrune or Twitter.
Do not text, email, phone or otherwise contact or communicate with anyone outside
the Company except the Emergency Services and those parties listed in Appendix 2.
In cases where persons claiming to be next of kin, make enquiries, you must still respond
that you are unable to confirm anything but ask for contact details so that you we can
contact them as soon as anything can be confirmed.
4.6.9
Secure the premises as an Incident Room. Lock the Office door. Close all windows and
ensure the office is cleared of anyone not immediately connected to the incident.
4.6.10
Open a Log of Actions and record every development with date and time.
4.6.11
Other customers and visitors should be requested to leave and be escorted to the car park as
the office is now designated an Incident Room and no longer open to the public.
4.6.12
Any persons accompanying someone whom you believe to be on board or involved in the
incident may remain but should be asked to wait in a briefing room and requested not to
communicate with anyone else until facts can be confirmed.
4.6.13
Impound the aircraft documents, the Authorisation sheets.
4.6.14
Once a member of Senior Management has taken over responsibility as EA they will:-
4.6.15
Contact Terry Holloway (Public Relations Director) at Marshall Aerospace to co-ordinate
any response to media enquiries.
4.6.16
Contact the Maintenance Organisation and request them to impound the maintenance
records.
4.6.17
Contact the aircraft owner to advise them of the situation.
4.6.18
Senior Management should consider any other third party organisations or agencies where
co-ordination is necessary or who will need to be kept informed.
4.6.19
A return to normal operations may only commence once Senior Management are satisfied
that the ERP and Accident Reporting Procedure have been fully completed and they will
instruct the EA to issue an instruction to return to normal operations.
4.6.20
The operation of the ERP is to be practiced annually to ensure staff are aware of
responsibilities and competent to carry out required actions. The ERP effectiveness and
performance shall be reviewed under item 6 of the Standard Agenda.
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4.7.
Continuous Improvement
It is our stated aim to see continuous improvement in our safety record. To that end, the
Safety Committee will regularly review the SMS to assess progress. A standard agenda
for SMS meetings is annexed in Appendix 1 which will form the basis of each meeting’s
agenda to which will be added any specific items requiring consideration. The annual
Safety Committee meeting will assess performance against the SPI targets and strive to
continue improving safety performance.
4.8.
Audits
As part of our commitment to continuous improvement, an annual SMS audit will be
carried out by the Company Compliance Manager as part of the ATO audits to assess
compliance. Such audit shall ensure compliance with the above procedures and ascertain
that mitigation measures are implemented and maintained successfully. Supplier (subcontractor) Audits are to be conducted on all our major suppliers as detailed in Audit
Plan contained in the Compliance Monitoring Manual. The Accountable Manager is
responsible for ensuring adequate corrective action is undertaken to address any
identified deficiencies brought to light during the audit; this may necessitate Residual
Risk Assessments and review by the Safety Committee. The Accountable Manager is to
follow up audit findings and monitor the effectiveness of the corrective actions taken.
4.9
Reviews
The Safety Management Committee will meet at least annually to discuss and review the
SMS, the SMS Manual and SPI’s to review its effectiveness in meeting its objectives. A
standard agenda for this meeting is included at Appendix 1.
Process & Procedure
• AM to submit report (Appendix 9) comparing effectiveness against SPI’s.
• Safety Committee will consider trends evident & make recommendations.
• Safety Manager will minute recommendations and ensure their implementation.
• Safety Manager will report such findings to the Board.
• Compliance Monitoring Manager will check implementation at next annual audit.
4.10
4.10.1
4.10.2
4.11
4.11.1
4.11.2
Contracted Activities
The Company may contract certain activities to external organisations for the provision
of services. The ultimate responsibility for contracted activities, i.e. for the product or
service provided by external organisations always remains with the Company.
A written agreement signed between the Company and the contracted organisation shall
clearly define the contracted activities and the applicable requirements.
Safety Management
Activities performed by sub-contractors may have an impact on safety, therefore, the
contracted safety related activities need to be addressed through the Company's safety
management and compliance monitoring programme.
As part of safety management, a risk analysis is to be carried out on any newly contracted
activity as part of the change management process. If corrective and/or preventive actions
need to be implemented, they are to be submitted in writing to the sub-contractors or
suppliers. Effective application of these measures needs to be checked and monitored
under the supervision of the Safety Manager
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4.12
4.13
4.13.1
4.13.2
4.13.3
4.13.4
4.14
4.14.1
4.14.2
4.14.3
Compliance Monitoring
As part of the Compliance Monitoring Programme, the Company must ensure that the
contracted organisation has the necessary authorisations or approvals where required, and
has the resources and competence to undertake the task. Compliance with applicable
regulations, Company requirements and procedures are to be checked and monitored
under the supervision of the Compliance Manager.
Safety Promotion
Safety Promotion is a process aimed at promoting a culture of safety by ensuring that all
personnel in an organisation are aware that, at their level and in their day-to-day activity,
they are key players in safety and that everyone, therefore, contributes to effective safety
management.
It is the responsibility of each manager to demonstrate his/her commitment to safety, to
promote safety in everyday activities and to lead by example.
Training and effective communication on safety are two important processes supporting
safety promotion.
The Safety Notice Board is maintained by the Safety Manager
Training & Education
All ATO personnel receive safety training as appropriate for their safety responsibilities.
The Safety Manager maintains records of all safety training provided.
All personnel receive training to maintain their competences. This includes notification
of any changes to applicable regulations and rules, Company procedures, and safetyrelevant technical matters.
The following table shows the safety training given to ATO employees.
Contents
4.14.4
SMS MANUAL
Training Objectives
Safety Policy
Understand the main elements of the Safety Policy.
Organisation, roles and responsibilities
Understand the organisation, roles and responsibilities
concerning the management of safety. Everyone to know his
or her own role in the management of safety.
Safety Objectives
Understand the Company’s safety objectives.
Emergency Response Planning (ERP)
(reinforced through practical simulations)
Understand the various roles and responsibilities in the
Company’s ERP. Everyone to know his or her own role in
the ERP.
Occurrence and hazards reporting
Know the means and procedures for reporting occurrences
and hazards.
Safety Risk Management (SRM) process
including roles and responsibilities
Understand the Safety Risk Management process. Everyone
to know his or her own role in the SRM.
Continuous improvement of safety
performance
Understand the principles of continuous improvement of
safety performance.
Compliance Monitoring
Understand the basic principles of Compliance Monitoring.
Responsibility when contracting activities
Understand the Company’s responsibilities when contracting
activities. Everyone should know his or her own roles and
responsibilities regarding this subject.
All existing staff received email notification of their safety roles and responsibilities and
received initial Safety Training the implementation of the SMS in December 2013. All
new staff will be given training and notice of their safety roles and responsibilities upon
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joining. Annual refresher training will be given to all staff each year thereafter. Upon
completion of training, a Staff Training Record will be completed which shall include a
declaration, signed by the trainee confirming their understanding and awareness of their
responsibilities and their confidence and trust in the Company Safety Policy and
reporting processes.
4.15
Safety Communication
Any new or amended safety information is to be disseminated as follows:
word of mouth communication with Key Personal to achieve the fastest possible
transmission, and
a mail shot style e-mail to all stakeholders, and
a general post on the Company website, and
a written notice on the Company notice board.
The Safety Manager will provide specific feedback by private email to the any
individual who originally raised a safety issue, clearly stating the Company’s
response and the mitigation measures to be adopted.
4.16
Safety Management System Documentation Suitability
The Company and its Board believe the Safety Management System to be adequate
and fit for purpose for an organisation of such small size. All elements required in
guidance material available at the time of implementation have been included as
considered applicable to an organization consisting of less than 4 employees.
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APPENDIX 1
SAFETY COMMITTEE STANDARD AGENDA
1
Minutes from last Safety Committee Meeting
2
Matters Arising
3
Review of Safety Policy
4
Review of Safety Policy Communication throughout Organization.
5
Emergency Response Plan Review
6
ERP Last Practice Review
7
SMS Manual Review
8
Safety Performance Indicator Review & Trend Identification
9
Safety Performance Report
10
Safety Performance and SMS Effectiveness Review
11
Organizational Changes – Identify any review necessary
12
Safety Audits Carried Out
13
Hazard Log Review
14
Feedback Check
15
AOB
16
Date for Next Meeting
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APPENDIX 2 - EMERGENCY RESPONSE PLAN
ACCIDENT REPORTING PROCEDURE
In the event of an incident or accident, carry out the following procedure immediately and
precisely. Stay calm and most importantly DO NOT TALK TO THE PRESS OR ANYONE
OUTSIDE OF THE COMPANY.

Contact (in order of priority):
DUNCAN BICKLEY:
07969 990 210 (M)
PHILIP SHELDON:
07831 559 903 (M)
JULIE SIMPER:
07867 524 012 (M)
ROBERT MACKENZIE: 07900 803 384 (M)
● Open Incident Log using format shown in Appendix 3.

Contact the AVIATION ACCIDENT INVESTIGATION BRANCH (AAIB)
Tel: 01252 512299 (24 hours)

Contact Cambridge Air Traffic Control: 01223 293737 and give them details of the
accident.

Contact the POLICE: 999 and provide the following information:
1. Your name, the Company Name, Address and Telephone Number:
AEROMEGA HELICOPTERS
CAMBRIDGE AIRPORT
CAMBRIDGE
CB5 8RX
2.
3.
4.
5.
6.
7.
Tel: 01223 294488
Nature of Accident.
Aircraft type.
Aircraft registration.
Number of people on board.
Names if known
Location of accident.
● Do not contact or disclose any details to next of kin until specifically authorised.
● Do not post comment on Social Media Sites e.g. Facebook, PPrune or Twitter.
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● Do not text, email, phone or otherwise contact or communicate with anyone outside the
Company except the Emergency Services, those parties listed above.
DO NOT DISCUSS ANY DETAILS OF THE ACCIDENT WITH ANYONE OUTSIDE
AEROMEGA
● Your standard response to every enquiry must be: “We are aware of an incident but we
are unable to confirm any details at this time. We shall be making a statement in due
course.”
● No further comment may be made, DO NOT RESPOND TO ANY QUESTIONS.
● In cases where persons claiming to be next of kin, make enquiries, you must still
respond that you are unable to confirm anything but take down contact details so that
you we can contact them as soon as anything is confirmed.
● Secure the premises as an Incident Room. Lock the Office door. Close all windows and
ensure the office is cleared of anyone not immediately connected to the incident.
● Other customers and visitors should be requested to leave escorted to the car park as
the Office is now designated an Incident Room and no longer open to the public.
● Any persons accompanying someone whom you believe to be on board or involved in
the incident may remain but should be asked to wait in a briefing room and requested
not to communicate with anyone else until facts can be confirmed.
● Impound the aircraft documents, the Authorisation sheets.
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APPENDIX 3
EXAMPLE
Incident Log
Date:
1/2/03
Time of Incident: 09:00
Helicopter Registration:
Date
Time
1/2/03 09:05
Aeromega Name of third party
Personnel and organisation
XX
John Smith, ATC
1/2/03 09:06
YY
DB Head of Training
1/2/03 09:08
1/2/03 09:09
XX
XX
Dick Williams AAIB
1/2/03 09:10
YY
John M, HeliWorld
1/2/03 09:25
XX
John Smith ATC
1/2/03 09:35
XX
DB
Detail of Interaction
Heavy landing and rollover of R22 at
H1 reported. No fire.
DB informed by mobile phone, he will
attend office in next 30 minutes.
Office door locked, Premises Secure.
Telephoned AAIB to inform them of
incident
Enquiry from JM for details of who
was on board, aircraft type etc.
Standard response given – unable to
confirm any details at this time.
ATC advise that 1 passenger injured
being taken to hospital, Pilot unhurt.
DB arrives and takes over as EA
Page 1 of X
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APPENDIX 4
STAFF TRAINING RECORDS
Name…………………………………………………………………………………………………..
SMS Manual Read
Signature……………………………….Date
/
/20
Initial Training Completed
Signature……………………………….Date
/
/20
Oral Test on ERP Passed
Signature……………………………….Date
/
/20
Revision Training Date
/
/20
Declaration
I understand the responsibilities and accountability contained in the Company Safety Policy
and SMS and undertake to comply with the necessary processes, decisions and actions required
of me.
I confirm that I have confidence and trust in the Company reporting policy and process.
Signed………………………………………………………………………………………………
Name……………………………………………………………………………………….
Date………………………………………..
SMS Initial Training Completed
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Signature……………………………….Date
Safety Manager
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APPENDIX 5
Risk Assessment (RA) for Change of Process.
Item
Risk Severity
Nature of Change Proposed
Person Responsible for RA
Date of RA Commencement
Legislative Requirements
Financial Risks Quantified
Commercial Risks Quantified
Previous Risk Assessments &
Existing Hazards Review for
possible effect
Consequences of Not Adopting
Proposed Change
Proposal to Board
Board Decision
Date of Authorisation to Adopt
Proposed Change
Staff Training Completed
Date Change Adopted
Signed by Safety Manager
Date
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APPENDIX 6
Hazard Log Entries Listing
P1 On airfield EOL crash landing
P2 Off airfield crash landing
P3 Emergency Landing Mountainous Terrain
P4 Emergency Open Water Ditching
P5 Fire during fuelling
P6 Fire in Office
P7 Fire in Hangar
P8 Injury sustained airside
P9 Helicopter damage sustained on ground
P10 Battery Charging
P11 Bowser contamination
P12 Bowser Towing
P13 Handling Fuel
P14 Injury whilst ground handling helicopters
P15 Bird Strike
P16 FOD
P17 Overspeed
P18 Runway Incursion
P19 Circuit Conflict
P20 Model Flying Conflicts at Bottisham
P21 Inadvertent entry into cloud
P22 New Instructor Brief
P23 Step Ladders
P24 Inadvertent infringement of controlled airspace
P25 Cables at Gliding Sites
P26 Dangers of Hangar Apron ops
P27 Solo Authorisation Process
P28 Use of Confined Areas
P29 Airport Works affecting operations
P30 Sloping Ground Training
P31 - EOL's from the hover
P32 - Unannounced Throttle Chops
P33 - Action in event of being unable to comply with ATC instructions
P33 - Hazards specific to SFH
P34 - Pilot not remaining at the controls until blades fully stopped
P35 - Rotors running crew changes
P36 - Pilot becoming unsure of position
P37 - Flying abroad
P38 Land's End John O'Groats Trip
P39 Flying as a Combine vs In Formation
P40 Navigation on Trips
P41 Calculating Points of No Return
P42 Weather Assessment
P43 CRM Issues
P44 Tripping Hazard
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P45 Alps Trip - Megeve Ops
P46 Essex Helicopters
P47 Off Airfield Flights to Student's Homes
P48 Damage to underside of R44 during towcart operation
P49 Inadvertent infringement of controlled airspace during dual training
P50 Unpredictable Student Response
P51 Fire on board
P52 Loss of Control Vortex Ring / Loss of Tail Rotor Effectiveness
P53 Now Cancelled
P54 Synchronisation of lookout reduces effectiveness
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APPENDIX 7
Safety Report & Hazard Log Form
Date:
Owner:
Contact:
Participants: D. Bickley (Accountable Manager), I. Mills (Staff Instructor),
Reported by:
Date Reported:
MOR filed: (yes/no): Yes
Follow up review date:
Example Safety Report & Hazard Log Form / Risk Assessment
Identified Hazard
Bowser Battery Charging
Associated Risk
Existing Mitigation
Measures in place
Current Level of
Risk
Sparks might ignite fuel vapour
Battery must not be charged in situ. Must be removed from bowser and charged in the
designated charging shed.
Severity 5
Likelihood 3
Tolerability = 15 Unacceptable
Reiterate Bowser operation procedures to all instructors by annual refresher training.
Further Mitigation
Measures
Revised Level of Risk Severity 5
Action By
Likelihood 1
Tolerability = 5 Review
C.Mayes
Diarise Refresher Training
Follow Up Action
Resources Required:
DB to organise refresher training for instructors.
Responsibility for Action
Feedback given to Staff
D. Bickley
Follow up action req’d
Agreed By:
Date:
VERSION EASA 2
Communicate refresher training requirement to all
stakeholders.
Who: C. Mayes
When xx/xx/xx
DB
Safety Officer/Accountable Manager
xx/xx/xx
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APPENDIX 8
Roles and Responsibilities:
1
Accountable Manager, Head of Training (HT), Safety Manager
These are combined roles and as such the combined post holder shall be responsible to the
Board of Directors for:
•
Establishing and maintaining an effective management system
•
Ensuring that the organisation has sufficient qualified personnel for the planned tasks
and activities
•
Promoting the highest degree of safety awareness throughout the organisation
•
Ensuring that all activities can be financed
•
Ensuring that the training provided is in compliance with Part-FCL.
•
Ensuring the satisfactory integration of flight or synthetic flight training with
theoretical
•
Supervising the progress of individual students
•
Fostering the highest degree of safety awareness throughout the organisation
•
Liaison with the competent authority
•
Acting as the focal point for safety issues
•
The development, administration and maintenance of an effective safety management
system
•
Facilitating hazard identification, risk analysis and management
•
Monitoring the implementation of actions taken to mitigate risk
•
Providing periodic reports on safety performance
•
Ensuring the maintenance of safety management documentation
•
Ensuring that safety management training is available and that it meets acceptable
standards
•
Providing advice on safety matters
•
Ensuring the initiation and follow-up of internal occurrence/accident investigations
2
Compliance Monitoring Manager
The Compliance Monitoring Manager is responsible to the Accountable Manager for:
•
Monitoring the compliance of the organisation with all applicable regulatory
requirements
•
Monitoring the compliance of the organisation with the provisions of the Operations,
•
Training and Safety Management Manuals
•
Ensuring that the compliance monitoring programme is properly implemented,
maintained and continually reviewed and improved
•
Ensuring that audits are conducted by suitably trained and independent personnel
3
All Other Staff
All other staff are responsible for complying with, implementing and promoting and
improving this Company Safety Management System
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APPENDIX 9
Small Operator Safety Objectives and Safety Performance Indicators
Performance Indicator
Number of Major risk incidents (MOR)
Objectives (per
annum)
1 or less
Number of audit findings
4 or less
Number of ERP drills
1
Safety Report & Hazard Log forms
raised
Number of Safety bulletins issued
3 or more
Number of formal risk assessments
3
Loss of Control (V/R, LTE, Dynamic
Rollover)
Runway Incursion
1 or less
Airborne Conflict
3 or less
Controlled Flight into Terrain
1 or less
Ground Handling
2 or less
Fire
1 or less
Unplanned Landings
2 or less
CRM Issues
5 or less
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Current Year + 1
4
2 or less
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Year + 2 Year + 3 Year + 4