Angeles City Flying Club
Safety Management System
This page is being update to the latest version of the Safety Management System.
Press the SMS Version button to the right to see the current version information.
An Original copy of the latest SMS Document may be obtained through written request to :
Angeles City Flying Club, Inc.
Postal address: Woodland Airpark Talimundok, Sta. Maria Magalang, Pampanga Philippines.
Email Address: office@angelesflying.com
Contents
| Section Reference | Section Title | Revision No. | Date |
| SM 2 | INTRODUCTION & SCOPE | 0 | 01.10.2021 |
| SM 3 | DEFINITIONS & TERMINOLOGIES | 0 | 01.10.2021 |
| SM 4 | SAFETY POLICY & OBJECTIVES | 0 | 01.10.2021 |
| 4.0 | Management Commitment | ||
| 4.1,4.2 | ACFC Safety Policy | ||
| 4.3 | Safety Objectives | ||
| SM 5 | ACCOUNTABILIT & RESPONSIBILITY | 0 | 01.10.2021 |
| 5.1 | Accountable Executive | ||
| 5.2 | ACFC Organization Chart | ||
| 5.3 | Accountability and Responsibilities | ||
| 5.3.1 | Safety Officer | ||
| 5.3.2 | General Manager | ||
| 5.3.3 | Chief Mechanic | ||
| 5.3.4 | Chief Ultralight Flight Instructor | ||
| 5.3.5 | Ultralight Instructors | ||
| 5.3.6 | Administration – Officer-in-Charge | ||
| 5.4 | Safety Committee | ||
| 5.4.1 | Safety Committee Procedures | ||
| 5.4.2 | Safety Inspections | ||
| 5.5 | Safety Function Responsibility | ||
| 5.6 | Safety Reporting System | ||
| 5.7 | Management of Safety Reports | ||
| SM 6 | SAFETY RISK MANAGEMENT | 0 | 01.10.2021 |
| 6.1 | Risk Assessment and Management | ||
| 6.2 | Risk categories | ||
| 6.3 | Hazard Identification Methodologies | ||
| 6.4 | Risk Levels and Matrices | ||
| 6.5 | Safety Risk Mitigation Strategies | ||
| SM 7 | SAFETY INVESTIGATION | 0 | 01.10.2021 |
| 7.1 | The Investigation Process Model | ||
| 7.2 | The Investigation Process | ||
| SM 8 | INTERNAL AUDITS | 0 | 01.10.2021 |
| 8.1 | Responsibility | ||
| 8.2 | Audit Team | ||
| 8.3 | Audit Plan | ||
| 8.4 | Audit Findings and Follow Up | ||
| SM 9 | SAFETY MANAGEMENT REVIEW | 0 | 01.10.2021 |
| 9.1 | Responsibility and Applicability | ||
| 9.2 | The Review | ||
| 9.3 | Management Review Records | ||
| SM 10 | PROCESS, DOCUMENT & DATA CONTROL | 0 | 01.10.2021 |
| 10.1 | Safety Manual | ||
| 10.2 | Managing Changes | ||
| 10.3 | Document and Data Control | ||
| SM 11 | CONTINUAL IMPROVEMENT OF THE SMS | 0 | 01.10.2021 |
| 11.1 | Safety Manual | ||
| 11.2 | Safety and Cultural Surveys | ||
| 11.3 | Safety Inspections and Safety Committee Meetings | ||
| 11.4 | Management Reviews | ||
| 11.5 | Internal Audits | ||
| SM 12 | SAFETY PROMOTION | 0 | 01.10.2021 |
| 12.1 | Safety Education and Training | ||
| 12.2 | Safety Communication |
SM 2 - Introduction & Scope
2.0 Introduction
2.1 Introduction
SM 3 - Definitions & Terminologies
- Acceptable Risk: Residual risk identified after a risk assessment process. No additional safety risk control measure is necessary.
- Accident: An unplanned, unexpected occurrence that results in death, injury, occupational illness, damage to the environment or damage/loss of equipment or property.
- ALARP (As Low As Reasonably Practicable): The ALARP principle establishes the relationship between the cost and benefit of implementing controls and the acceptability of risk in the Club.
- Assessment: It is the process of describing, collecting, recording, and interpreting information about the safety culture of the Club and the effectiveness of the SMS.
- Asynchronous online teaching: Where the teaching materials are posted online, and learners work through them on their own schedule. Methods of delivering asynchronous online teaching may include but not be limited to, self-guided modules, video content, online libraries or resources, presentations, and lecture notes.
- Audit: A systematic, independent, and documented process for obtaining objective evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled. (Ref: ISO 9000:2015)
- Briefing: A meeting to convey facts, information, detailed instructions, or a summary of events. This can be delivered in a classroom or online.
- CAAP: The Civil Aviation Authority of the Philippine is a multi-role government agency responsible for the regulation of aviation in the Philippines. CAAP’s mandate covers a number of different functional areas, including responsibility for air traffic management.
- Campaign: A planned, and organized series of actions intended to achieve a specific goal or raising people’s awareness of something.
- Club: In this manual, the term refers to the Angeles City Flying Club (ACFC).
- Conformity: Fulfilling or complying with a requirement (Ref: ISO 9000:2015). This includes but is not limited to compliance with Government regulations.
- Consequence: Outcome of an occurrence affecting the safety objectives of the Club. (Ref: ISO Guide 73:2009)
- Correction: Action taken to eliminate a detected nonconformity. (Ref: ISO 9000:2015)
- Corrective Action: Action to eliminate (remove) or mitigate (lessen) the root cause or reduce the effects of a detected non-conformity or other undesirable (unwanted) condition and to prevent recurrence. (Ref: ISO 9000:2015)
- Document/Documentation: Information and the medium on which it is contained. (Ref: ISO 9000:2015). It is the method of internally capturing all the information necessary to properly execute organizational systems and processes. In this manual, it refers to the written description of various policies, objectives, processes, requirements, authorities, responsibilities, work instructions, etc.
- Evaluation: It is the process of making judgments based on criteria and evidence gathered during audits and inspections.
- Hazard: Potential sources of harm or detriment to people, assets, environment, systems, processes, and the Club’s reputation.
- ICAO: The International Civil Aviation Organization.
- Incident: An unplanned, unexpected occurrence, other than an accident, that could have resulted in death, injury, occupational illness, damage to the environment or damage/loss of equipment or property. A near miss episode.
- Interested Party: A person or organization that may affect, be affected, or perceive itself to be affected by a decision or activity of the Club.
- Nonconformity: Non-fulfilment of a requirement (Ref: ISO 9000:2015). This could include but is not limited to non-compliance with Government regulations and/or Club requirements. Activities that do not follow laid down norms or fail to comply with requirements or accepted standards are defined as non-conformities which includes unintentional events.
- Operational (or Activity) Life Cycle: The time period from implementation or introduction of a procedure, product, or service until it is no longer in use. The typical stages include development, introduction, growth, maturity, and decline.
- Organization: Certificated and non-certificated aviation organizations, aviation service providers, air carriers, airlines, maintenance, and repair entities, air taxi operators, corporate fight departments, repair stations, and collegiate aviation schools.
- Oversight (or Safety Oversight): A function performed by a regulator, such as CAAP, to ensure that individuals and aviation organizations performing an aviation activity comply with safety-related national laws, standards, requirements, and regulations.
- Preventive Action: An action taken to eliminate the cause of a potential nonconformity or other potential undesirable situation. It is an action to prevent occurrence. (Ref: ISO 9000:2015)
- Procedure: A specified way to carry out an activity or a process. (Ref: ISO 9000:2015)
- Process: A set of interrelated or interacting activities that use inputs to deliver an intended result. (Ref: ISO 9000:2015)
- Record: A document stating results achieved or providing evidence of activities performed. (Ref: ISO 9000:2015)
- Residual Safety Risk: The remaining risk, after assigning all possible mitigation measures.
- Review: It is an independent activity designed to determine the suitability, correctness, adequacy or effectiveness of the Club’s policies, objectives, procedures, and systems and to achieve continual improvement of the SMS.
- Risk (or Safety Risk): The effect of uncertainty. (Ref: ISO 9000:2015). The chance of something adverse happening The projected likelihood and severity of the consequences of an event.
- Risk Assessment: A process of identifying hazards, assessing risks, taking action to eliminate or reduce risk, monitoring and reviewing until safe completion of a task.
- Risk Level: The degree of the risk, considering the severity of the consequences and likelihood of occurrence. It could be intolerable, tolerable, or acceptable.
- Risk Mitigation: The process of incorporating defences, preventive controls, or recovery measures to lower the severity and/or the likelihood of a hazard’s projected consequence.
- Risk Occurrence: Any unplanned or unexpected safety event, such as a safety mishap, accident or incident that would cause concern for the safety of the members, ultralight instructors, employees, equipment, property, or the environment.
- Risk Probability: The likelihood of a hazard realising. It can be extremely improbable, improbable, remote, occasional, or frequent.
- Risk Severity: The outcome of a hazard. It can be negligible, minor, major, hazardous, or catastrophic.
- Safety: A state in which risks associated with Club activities, and activities related to, or in direct support of the operation of the aircraft, are reduced and controlled to an acceptable level.
- Safety Assurance: A formal management process within the SMS that systematically provides confidence that an organization’s products and/or services meet or exceed safety requirement and continue to achieve their intended objectives. The three main components of Safety Assurance include, safety performance monitoring and measurement, managing change and continual improvement.
- Safety Culture: It is an expression of individual and group values, and of how safety is perceived, valued, and prioritized by management and the employees. It is the product of attitudes, competencies, and patterns of behavior that determines the style, commitment to and proficiency of the organization’s management of safety. When visibly supported by upper- and middle management, frontline employees and members tend to feel a sense of shared responsibilities towards achieving their safety objectives. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety and by the confidence in the efficacy of preventive measures.
- Safety Management System: A systematic approach to managing safety, including the necessary organizational structures, accountability, responsibilities, policies, objectives, and procedures.
- Safety Objectives: A brief high-level statement of safety achievement or desired outcome to be accomplished by the SMS. The Safety Objectives are generally based on the organization’s Safety Policies and are typically measurable.
- Safety Planning: A basic element of the SMS that enables the setting of the Club’s safety objectives and targets, as well as the identification of the necessary means and resources for their achievement.
- Safety Promotion: A combination of education, training, safety communication and safety information sharing-activities that support the implementation and effectiveness of an SMS in an organization and encourages a positive safety culture.
- Safety Risk Management: A key component within the SMS and is a formal process that describes the system, identifies the hazards, assesses the risk, analyzes the risk, and mitigates the risk. The SRM process is integral to the processes used to provide the products and/or services.
- Seminar: Any meeting or gathering for exchanging information and holding discussions, usually on a specific subject or topic.
- Synchronous teaching: Where the teacher and the learner are present at the same time, i.e., in real time in a classroom or online.
- Teaching and Learning Aid (TLA): Any stimulus material that a trainer uses in order to promote effective learning.
- Tolerable Risk: Residual risk after a risk assessment process, where risk has been reduced to ALARP. Cost and time factors permitting, additional risk mitigation measures could be considered. It may require management decision to accept the risk.
- Trainer (or Instructor): A designated person at the Club who facilitates transfer of knowledge, understanding, skills and attitudes. A trainer may be referred to as a lecturer, tutor, teacher, educator, or faculty.
- Training Activities (or Instructional Activities): All activities organized by ACFC in order to transfer knowledge, skills, or attitudes, such as courses, computer-based training, E-learning sessions or self-study programmes.
SM 4 - Safety Policy & Objectives
4.0 Management Commitment
The Management of ACFC is committed to ensure a safe environment for all employees, members, and visitors at our facilities and in our club-owned aircraft. It recognizes and understands its duties and importance of taking an active and leading role in the effective implementation and continual improvement of the Safety Management System. This is achieved by:
- The Management’s decision-making activities and allocation of appropriate resources, which are consistent with the Safety Policies and the Safety Objectives, with the aim of cultivating a positive safety culture within the Club.
- Regularly participating in the internal audits and inspections of the Club with reference to the Club rules, CAAP regulations, as well as other industry best practices.
The Management will further demonstrate its accountability and commitment by providing the necessary support and resources with respect to financial, material, and human resources.
4.1 Safety Policy and Objectives
The Angeles City Flying Club shall take the necessary steps to develop and deeply embed a safety culture that recognizes the importance and value of effective safety management and acknowledges that safety is paramount and integral to the operation of the Club.
The Safety Policy of ACFC shall be communicated to all employees and members and measures taken to ensure that it is understood. The ACFC Safety Policy and Objectives shall be reviewed for continuing suitability during the annual Management
Review.
4.2 ACFC Safety Policy
The Angeles City Flying Club is committed to developing, implementing, maintaining, and constantly improving strategies and processes to ensure that all our aviation activities take place in a safe environment. To this end, the Management has
decided that:
- All levels of members, and employees are either responsible or accountable for the highest level of safety performance.
- All levels of members, and employees must be committed to operating in safe, healthy, secure working conditions and promoting safety attitudes with the objective of having an accident-free workplace.
- ACFC will endeavor to implement a just culture that will provide an atmosphere of trust to encourage people to provide essential safety feedback and information.
- ACFC will not take disciplinary action against any employee, member, or guest who discloses a safety concern unless such disclosures indicate, beyond reasonable doubt, an illegal act, gross negligence, deliberate or willful disregard of
regulations or procedures. - ACFC will provide its members and employees the necessary education, training, and information needed to promote safety and maintain the effectiveness of the Safety Management System.
- ACFC will always operate in compliance with the Philippine laws and the CAAP regulations.
4.3 Safety Objectives
To achieve the stated Safety Policy, the Angeles City Flying Club has established the following safety objectives:
- Define roles, responsibilities, authority, and accountability for the various levels of members and employees to achieve the stated safety performance of the Club.
- Identify safety training needs of members and employees and develop or procure suitable value-added programs and courses to address such needs.
- Plan, develop, and conduct safety seminars, campaigns or training programs required to promote safety, raise safety awareness, communicate, and implement a policy of trust and just culture, and maintain the effectiveness of the Safety
Management System. - Determine and maintain the safety systems necessary to meet current legal and regulatory requirements and plan for changes that may become necessary due to amendments to the applicable legal and/or regulatory frameworks of the Philippine Government and the CAAP, to ensure that the Club is in full compliance with the relevant safety requirements.
- Integrate safety assurance functions into all activities of the Club.
SM 5 - Accountability & Responsibility
5.1 Accountable Executive
The President of Angeles City Flying Club is the Accountable Executive and has the ultimate authority over the safe operation of the Club. The President has the responsibility for the overall safety performance with the authority to take action to ensure the SMS is effective. The President has the following safety accountabilities:
- Provide the necessary financial, material, and human resources to implement and maintain an effective SMS and for its continual improvement.
- Establish and promote the Safety Policy and Safety Objectives.
- Review the Club’s SMS, Safety Policy and Safety Objectives on an annual basis.
- Promote a positive safety culture and a visible environment of just culture.
- Identify a competent person to fulfil the role of a Safety Officer, who will be essential for establishing an effectively implemented and functioning SMS.
The President has the final authority for the resolution of all safety issues and over the operations of the Club, including the authority to stop the operation or activity.
5.2 ACFC Safety Organisation Chart
The Organisation Chart represents the hierarchy of and interfaces between key positions and functions within the ACFC Safety Management System and where applicable, the interfaces with external organizations providing products or services, supporting and/or affecting the safety systems of ACFC.
This Organisation Chart shall be displayed at a prominent location for the information of all ACFC employees and members.
5.3 Accountability and Responsibilities
Accountabilities and responsibilities of all personnel, management and employees involved in safety-related duties have been defined.
5.3.1 Safety Officer
- Manage the SMS implementation plan on behalf of the accountable executive.
- Perform and facilitate hazard identification and safety risk analysis.
- Conduct Safety Inspections and assist functional area managers with hazard identification.
- Report findings of hazardous conditions, occurrences, and near-misses to the General Manager.
- Conduct accident or incident investigations and monitor corrective actions and evaluate their results.
- Plan and facilitate employees’ safety training including training to handle ACFC emergencies based on their role in the organization.
- Train members of the Safety Committee on the SMS as enshrined in this SM Manual.
- Prepare and present audit/inspection reports and remedial actions.
- Maintain all safety related documentation and records, including the minutes of the safety meetings.
- Provide independent advice on safety matters and promote safety in the Club by encouraging safe work practices and through the display of posters, notices, and other such means of dissemination of safety information.
- Implement and follow through all decisions and action plans of the Safety Committee.
- Publish an annual report of all items brought before the Safety Committee and the status of each item including actions implemented.
- Ensure new employees and members are provided with a safety induction briefing.
5.3.2 General Manager
- Ensure all operations personnel understand and comply with applicable regulatory requirements, standards, and the organization’s safety policies and procedures.
- Identify and develop resources to achieve safe Club operations.
- Review standards and practices of Club personnel as they affect the Club’s safety.
- Conduct weekly safety inspections of operations and report findings or deficiencies. Communicate directly with the Safety Officer regarding items that need immediate attention
5.3.3 Chief Mechanic
- Ensure all maintenance personnel understand applicable regulatory requirements, standards, and Club safety policies and procedures.
- Identify and develop resources to achieve safe maintenance operations.
- Observe and control safety systems by monitoring and supervising maintenance personnel.
- Measure performance compliance of club aircraft maintenance personnel with the Club’s goals, objectives, and regulatory requirements.
- Review standards and the practices of maintenance personnel as they affect flight safety.
- Conduct weekly safety inspections of flight operations and report findings and deficiencies. Communicate directly with the Safety Officer regarding items that need immediate attention.
5.3.4 Chief Ultralight Flight Instructor
- Ensure all ultralight instructors understand applicable regulatory requirements, standards, and Club safety policies and procedures.
- Observe and control safety systems by monitoring and supervising ultralight instructors and ultralight pilots.
- Measure performance compliance of ultralight instructors and ultralight pilots with the Club’s goals, objectives, and regulatory requirements.
- Review standards and the practices of the ultralight instructors and ultralight pilots as they affect flight safety.
5.3.5 Ultralight Instructors
- Under the direction of the Chief Ultralight Flight Instructor, ensure that club pilots meet regulatory requirements, standards, and Club safety policies and procedures.
- Conduct monthly safety inspections of all Club aircrafts to ensure they are in safe and proper working order. Submit the results to the Chief Ultralight Flight Instructor and the Safety Manager.
5.3.6 Administration - Officer-In-Charge
Safety
Maintain all fire prevention and firefighting equipment as per local fire department and Club rules and maintain appropriate records.
Maintain the inventory and monitor the expiry dates of all First-Aid kits.
Security
Ensure that the security guards monitor the CCTV cameras and report all events.
Ensure, with the assistance of the security guards and other ACFC employee or member, that visitors do not breach any restricted area perimeter.
5.4 Safety Comittee
The purpose of the Safety Committee is to promote the safety, health, and welfare of ACFC’s members, employees, and the aviation community, in general. In addition, the committee will act proactively to:
- Ensure the safe operation of equipment and facilities.
- Ensure compliance with the applicable regulations of local, provincial, and national authorities.
- Seek ways to eliminate unsafe practices by employees and Club members.
- Conduct aircraft-related incident and accident investigations.
- Enhance and protect the Club’s self-insurance programs
The Safety Committee will be accountable and report to the President of The Angeles City Flying Club. The General Manager should provide the Safety Officer and the Safety Committee with all required information to perform their duties.
The Safety Committee Composition:
5.4.1 Safety Committee Procedures and Responsibilities
- The Safety Committee shall meet at intervals of not more than one month and whenever the committee deems it necessary.
- The Chairperson shall fix the date of each monthly meeting and decide any specific agenda that needs to be included, which will then be communicated to the members in sufficient time before the meeting.
- Additionally, hold an extraordinary safety meeting,
- in case of any incident or accident, belonging to a severity category of “major” and above, within 48 hours, to discuss the event, its causes and formulate the safeguards to prevent its recurrence.
- on receiving an urgent regulatory change notice, within a week of receiving such notice or memorandum. Form SM-ESM shall be used to capture the meeting minutes.
- Safety Meeting Agenda:
The standard agenda of every safety meeting shall comprise of the following items:- Minutes of the previous meeting:
- Discuss and record all findings of the previous meeting, which required actions and are now completed.
- Carry forward the pending items until completed with follow-up action.
- Record the reasons for not completing any item within the assigned target completion date.
- Safety Officer’s Inspection report – discuss the results of the inspection and decide on the corrective actions required for each finding.
- Discussion of all accidents, incidents and unsafe conditions that have occurred, including all “Safety Observation” cards received, since the last meeting.
- Discussion on any new rules or regulatory changes that affect the Club operations and need to be implemented.
- Invite suggestions for improvement of the SMS from the committee members.
- Any other business or topics for discussion.
Form SM-SCM shall be used to capture the meeting minutes.
- Minutes of the previous meeting:
5.4.2 Safety Inspections
The Safety Officer shall prepare an inspection schedule of all operational areas of the Club spread over a period of two months, covering half the areas each month.
The Safety Officer shall carry out the inspection assisted by an Officer-in-Charge from another area of operation. This will bring together the knowledge of both areas of operations, create more objectivity and limit individual bias. The safety inspection should be carried out prior to the date of the Safety Committee Meeting announced for that month.
When conducting safety inspections, the inspection team should:
- Plan a slow and thorough walk-through of the selected area.
- Identify hazards to health, safety, and environment.
- Initiate corrections for hazardous conditions of an urgent nature and which could be rectified immediately.
- Plan the corrective actions for other items based on priority and assign a target date and a responsible person for closure
- Discuss the findings of inspections during the Safety Committee meeting and record the items in the Safety Meeting report.
Checklist SM-SIC shall be used to conduct the inspection.
5.5 Safety Function Responsibility
| Sr No | Section Title | Responsibility |
| .1 | Identifying, recording, and reporting, safety deficiencies related to all Club activities | All employees and members |
| .2 | Voluntary Incident and Accident reporting | All employees and members |
| .3 | Mandatory Incident and Accident reporting | All employees and members |
| .4 | Recommending and providing safety solutions through designated channels | All employees and members |
| .5 | Initiating and implementing action to prevent occurrence or reoccurrence of non-conformities | Safety Officer, General Manager |
| .6 | Controlling the process until the deficiency has been corrected | All Safety Committee members |
| .7 | Verifying the effectiveness of implemented solutions | General Manager, Safety Officer |
| .8 | Promotion of safety, safety awareness and just culture | General Manager, Safety Officer |
| .9 | Review of SMS manual | Safety Officer |
| .10 | Reviewing and monitoring the effectiveness of the Safety Management System | General Manager, Safety Officer |
5.6 Safety Reporting System
The Angeles City Flying Club is committed to the promotion of a non-punitive environment, where all Club employees, and members can voluntarily report safety issues, errors, mistakes, and even violations, without fear of disciplinary action from the Club management. The Club will not initiate punitive actions against any individual who discloses a safety related occurrence or concern, unless such disclosures indicate, beyond reasonable doubt, an illegal act, gross negligence, deliberate or willful disregard or infractions of Club Rules, the Safety Management System, CAAP regulations, the Philippine laws, and basic practices of good airmanship.
Dr. James Reason termed this corporate attitude as a “Just Culture.” The figure below illustrates the accountability of people within our Club. A Just Culture provides guidelines that differentiate between acceptable and unacceptable behavior.
Just Culture Flowchart (source: ICAO, 2018)
Adapted from: “A Decision Tree for Determining the Culpability of Unsafe Acts” by Dr. James Reason (1997)
The ACFC has two main safety reporting systems
- Voluntary Safety Reporting System
A voluntary safety reporting system has been established to collect safety data and safety information not captured by the mandatory safety reporting system. These reports go beyond typical incident and accident reporting. Voluntary reports illuminate latent factors, such as inappropriate or deficient safety procedures or regulations, unsafe or substandard conditions, design or system flaws, and active factors like substandard or unsafe acts, deviation from usual or documented operational procedures, violations, etc. In general, any safety concern that would be of interest to other ACFC members or employees, should be reported.- The “Safety Observation Card” (SOC) is utilized for making such reports. The individual submitting this card may choose to submit an “Anonymous Report” or a “Confidential Report”. The report can either be submitted in hard copy format, or as an email attachment.
- For ease of availability, the Safety Observation Cards are placed at various convenient locations but specifically at the following locations:
– Guard House
– RC/Parking area
– Training Room
– Office
– Hangers
– Cafeteria
- Mandatory Safety Reporting System
Mandatory Safety reporting systems provide for the capture of some specific hazards, mostly technical or hardware failures, which are known to contribute to accidents, the timely identification and communication of which, is considered valuable to enhance safety of flight operations.
The following events, amongst others, must be considered as mandatory for reporting:- If evasive action was taken due to loss of aircraft separation and/or possible collision
- Any instance of inadequate terrain clearance
- Pilot’s loss of situational awareness resulting in his/her loss of position for more than 15 minutes
- Failure of navigation or communication systems
- Electrical failure resulting in a precautionary landing
- Any physical damage to the aircraft, propeller, Club property, or people
- Any unintentional exit from a designated surface while landing, taking off, or taxiing
- Critically low fuel quantity or landing with less than the prescribed fuel load
- Severe turbulence
- Engine failure or partial power loss
- Any ditching or controlled landing that is not on an airport runway
- Any intentional or unintentional violation of ACFC’s Standard Operating Procedures
- Any runway incursion
- Landing on the wrong runway or at the wrong airport
- Any departure or excursion from the runway
- Weather related injury or damage
- Significant fuel leak
- Takeoff with a significant weight and balance error
- Injury to any person while in or outside the aircraft
- Lightning strike or bird strike
- Loss of Control – inflight
- Loss of Control – ground
- Damage to aircraft by ground equipment
- Damage to non-ACFC Aviation property
- Fire, explosion, smoke, or toxic fumes in or on the aircraft
Notwithstanding the above listed items, and as a general guidance, all employees and members must report an event when they believe that,
- there were circumstances that were indicating a high probability of an accident, or
- an accident was avoided only due to providence.
The “Accident and Injury Report”, Form SM-AIR is utilized for making such reports.
Note: Reporting Aircraft Accidents and Serious Injuries to CAAP:
Aircraft accidents, serious injuries, or a death, will be reported immediately, and by the most expeditious means available, to the Authority/Chairman accordance with CAAP’s PCAR Part 13
guidelines and regulations.
Safety Investigation Decision Process (adapted from: ICAO Doc. 9859)
5.7 Management of Safety Reports
- The designated custodian of both the above types of reports will be the Safety Officer.
- Under no circumstances will the Safety Officer disclose the identity of the reporter to any ACFC personnel, any other organization, agency, or person without the express permission of the reporter.
- On receipt of a safety report, the Safety Officer will give positive feedback to the reporter and an assurance that the safety concern/s will be taken up by the Safety Committee for appraisal and investigation as necessary.
- If the safety concern is of an urgent nature, or the perceived risk possesses the severity or potential severity level of major or higher, then the General Manager shall be notified immediately by the most expeditious means possible, to determine the appropriate action to prevent any harm to people or asset.
- The Safety Officer will present all safety reports to the Safety Committee for discussion and investigation, and if necessary, for root cause analysis and deciding the appropriate corrective or preventive actions.
SM 6 - Safety Risk Management
6.0 Safety Risk Management
The safety management system of ACFC utilizes a risk-based approach when creating systems, procedures, and methodologies of work particularly for those processes which directly or indirectly affect the safety of flight operations. The safety system also considers risks posed by external factors which could have an undesirable impact on the Club itself and which could adversely affect the operating environment of ACFC.
The following risk management decision aid is utilized when safety concerns are reported or detected:
Safety Risk Management Decision Aid (Source: ICAO Doc. 9859)
6.1 Risk Assessment and Risk Management
The Risk Assessment and Risk Management procedure comprises of the following stages:
- Identification of hazards or potential hazards.
- Determining the consequences of the hazards.
- Applying existing control measures.
- Determining Existing Risk Level.
- Applying additional measures, if required, to further reduce the risk to ALARP. Check for unintended consequences.
- Determining Final Risk Level.
- Determine Risk Acceptability.
- Review of existing Risk Assessments to identify new hazards and their associated risks, because of changes in the operating environment
6.2 Risk Categories
The ACFC has identified the following categories of risks that can affect the safe operations and the services provided by the Club:
- People (employees, members, visitors and third party)
- Asset (Club infrastructure, aircrafts, machinery, equipment, spares, tools, fuel, etc.)
- Process (flight operations, hanger administration, food and beverages, and office administration)
- Organization (legal, reputation)
Under each category, various hazards and their associated risks have been identified, possible consequences determined, and
control measures put into place.
6.3 Hazard Identification Methodologies
The two main methodologies utilized to identify hazards are:
- Reactive: Through the analysis of past outcomes or events, typically accomplished by investigating internal incidents and accidents.
- Proactive: Through the analysis of existing situations, programs, processes, and procedures typically identified during audits, inspections, and employee or member reporting.
Hazards are primarily identified through:
- Voluntary safety reporting system (e.g., Safety Observation
Cards) - Mandatory safety reporting system
- Safety meetings
- Audits
- Inspections
- Experience feedback
- External investigation reports (e.g., ICAO, CAAP)
6.4 Risk Levels and Matrices
6.4.1 Safety Risk Probability
To determine the Risk Level, first the likelihood or probability of the occurrence is determined using the following matrix:
Table 1 – Safety Risk Probability (Source: ICAO Doc. 9859)
| Probability | Meaning | Value |
| Frequent | Likely to occur many times (has occurred frequently) | 5 |
| Occasional | Likely to occur sometimes (has occurred infrequently) | 4 |
| Remote | Unlikely to occur, but possible (has occurred rarely) | 3 |
| Improbable | Very unlikely to occur (not known to have occurred) | 2 |
| Extremely Improbable | Almost inconceivable that the event will occur | 1 |
6.4.2 Safety Risk Severity
Once the probability assessment has been completed, the next step is to assess the severity, taking into consideration the potential consequences related to the identified hazard. The following matrix is utilized to determine the risk severity.
Table 2 – Safety Risk Severity (Source: ICAO Doc. 9859)
| Severity | Meaning | Value |
| Catastrophic |
|
A |
| Hazardous |
|
B |
| Major |
|
C |
| Minor |
|
D |
| Negligible |
|
E |
6.4.3 Safety Risk Matrix
The safety risk rating index is thereafter created by combining the results of the probability and severity scores. This results in an alpha-numeric value. The following risk assessment matrix is utilized to determine the safety risk level.
Table3 – Safety Risk Matrix (Source: ICAO Doc. 9859)
| Risk Probability |
Meaning | ||||
| A Catastrophic | B Hazardous | C Major | D Minor | E Negligible | |
| Frequent 5 | 5A | 5B | 5C | 5D | 5E |
|---|---|---|---|---|---|
| Occasional 4 | 4A | 4B | 4C | 4D | 4E |
| Remote 3 | 3A | 3B | 3C | 3D | 3E |
| Improbable 2 | 2A | 2B | 2C | 2D | 2E |
| Extremely Improbable 1 | 1A | 1B | 1C | 1D | 1E |
6.4.4 Safety Risk Tolerability Table
The below table describes the tolerability criteria for ACFC.
The safety risks are assessed as Acceptable, Tolerable, or Intolerable. Safety risks assessed as Intolerable initially, are unacceptable under any circumstance.
Table 4 – Safety Risk Tolerability Table (Source: ICAO Doc. 9859)
| Color Zone | Score | Action/Decision Requirement |
| Intolerable Region | 5A, 5B, 5C 4A, 4B 3A |
|
| Tolerable Region | 5D, 5E 4C, 4D, 4E 3B, 3C 2A, 2B |
|
| Acceptable Region | 3D, 3E 2C, 2D, 2E 1A, 1B, 1C, 1D, 1E |
|
Note: Form SM-SRA is utilized to carry out task or operation specific risk assessments.
6.4.5 Tolerability of Safety Risks
The below table describes the tolerability criteria for ACFC.
The safety risks are assessed as Acceptable, Tolerable, or Intolerable. Safety risks assessed as Intolerable initially, are unacceptable under any circumstance.
Table 5 – Tolerability of Safety Risks
(Source: Quantified risk assessment modelling of aircraft landing operations – Scientific Figure on ResearchGate)
6.5 Safety Risk Mitigation Strategies
These are also referred to as safety risk control strategies. The level of safety risk is lowered by reducing the severity of the consequences, reducing the probability of occurrence or by reducing the exposure to that safety risk.
Three categories of safety risk mitigation strategies are utilized:
- Avoidance: The operation or activity is cancelled or avoided because the safety risk exceeds the benefits of continuing the activity, thereby eliminating the safety risk entirely.
- Reduction: The frequency of the operation or activity is reduced, or action is taken to reduce the magnitude of the consequences of the safety risk.
- Segregation: Action is taken to isolate the effects of the consequences of the safety risk or build in redundancy to protect against them.
6.5.1 Hierarchy of Hazard and Risk Controls
It is a systematic process used in Safety Risk Management to minimize or reduce exposure to hazards.
The triangle below shows the priority of actions in decreasing effectiveness from top to bottom in sequence.
6.5.2 Selection of Appropriate Strategies
A safety risk mitigation strategy may involve one or more of the approaches described above or may be a combination of them. Each proposed safety risk mitigation alternative is examined from the following perspectives:
- Effectiveness: The extent to which the alternatives reduce or eliminate the safety risks. Effectiveness can be determined in terms of the technical, training, and regulatory defenses that can reduce or eliminate safety risks.
- Cost/benefit: The extent to which the perceived benefit of the mitigation outweighs the costs.
- Practicality: The extent to which mitigation can be implemented and how appropriate it is in terms of available technology, financial and administrative resources, legislation, political will, operational realities, etc.
- Acceptability: The extent to which the alternative is acceptable to those people that will be expected to apply it.
- Enforceability: The extent to which compliance with new rules, regulations or operating procedures can be monitored.
- Durability: The extent to which the mitigation will be sustainable and effective.
- Residual safety risks: The degree of safety risk that remains after the implementation of the initial mitigation and which may necessitate additional safety risk control measures.
- Unintended consequences: The introduction of new hazards and related safety risks associated with the implementation of any mitigation alternative.
- Time: Time required for the implementation of the safety risk mitigation alternative.
SM 7 - Safety Investigation
7.1 The Investigation Process Model
The below ILCI (International Loss Control Institute) Loss Causation model explains the cause-and-effect sequence of an accident or an incident.
Effective safety management depends on quality investigations to analyze safety occurrences and safety hazards, and report findings and recommendations to improve safety in the operating environment.
7.1.1 Purpose of Safety Investigations:
The primary objective of a safety investigation, besides satisfying regulatory requirements, is to understand what happened, and how to prevent similar situations from occurring in the future by eliminating or mitigating safety deficiencies by:
- Identifying immediate and basic or root causes – human, technical and organizational factors,
- Determining the preventive and corrective actions to avoid similar situations or occurrences,
- Establishing trends in accident/incident causes,
- Establishing training needs,
- Identifying new hazards and assessing the risks,
- Making recommendations to reduce or eliminate unacceptable risks, and
- Identifying lessons learned that should be shared with the employees and members
Open investigations not only help in creating a positive safety culture within the organization but also improves profitability by preventing losses caused by accidents.
7.1.2 Investigation Triggers
A safety investigation will usually begin on receipt of a “Safety Observation Card” or when completing the “Accident and Injury Report Form”.
Not all occurrences can or should be investigated. The decision to investigate and its depth should depend on the actual or potential consequences of the occurrence or hazard. Occurrences and hazards considered to have a high-risk potential are more likely to be investigated and should be investigated in greater depth than those with lower risk potential.
The following decision-making questions are asked to determine which occurrences should be investigated and what should be the scope of the investigation. These questions include but are not limited to the following:
- what is the severity or potential severity of the outcome?
- what are the regulatory requirements to carry out an investigation?
- what is safety value to be gained?
- what are the opportunities for taking safety actions?
- what are the risks associated with not investigating?
- what will be the contribution to the SMS SPTs?
- what are the identified trends?
- what will be the training benefit? and
- what are the resources available?
7.2 The Investigation Process
The Form SM-AIR Accident and Injury Report will be used to conduct a structured investigation of an occurrence and to record the details. The techniques mentioned below will assist the investigator to carry out a thorough root cause analysis:
| The Big Picture |
|
| Interviews |
|
| Listen |
|
| Open-ended questions |
|
| 5W & 1H |
|
| Reconfirm understanding |
|
| Miscellaneous |
|
After collecting all information,
- Analyse the facts carefully. It is important to base judgments on facts and not on pre-determined views, opinions, and feelings.
- Prepare the report using sketches, photos, and descriptions. The readers should be able to understand the facts clearly through the report.
- Follow the guidance provided in the Form SM-AIR Accident and Injury Report to accomplish the report correctly and completely.
SM 8 - Internal Audits
Procedures have been established to carry out internal audits of the ACFC to verify the implementation of the SMS and to determine its effectiveness.
The audits will be conducted against the Safety Management System described in this Safety Manual.
8.1 Responsibility
The Safety Officer will ensure that,
- The internal audit is conducted at least once a year.
- Internal audits are carried out as per documented procedures.
- Records are maintained of audit reports, corrective action requests and observations.
- The effectiveness of initiated preventive or corrective actions is monitored.
- The online Non-Conformance Log SM-OIL is used to monitor the occurrence or recurrence of a non-conformity for which a preventive or corrective action had been earlier initiated.
- Corrective action requests are closed within the time frame.
- Corrective action requests are closed on the basis of objective evidence that demonstrates that the proposed corrective action/s are effective.
8.2 Audit Team
The Safety Officer will request the General Manager to carry out the audit of the SMS. The General Manager may appoint suitable Safety Committee members to conduct the audit. The Safety Officer cannot be one of the auditors and Safety Committee members appointed as auditors, cannot audit their own area of operations.
8.3 Audit Plan
8.3.1 Methodology
The primary objective of a safety investigation, besides satisfying regulatory requirements, is to understand what happened, and how to prevent similar situations from occurring in the future by eliminating or mitigating safety deficiencies by:
- Identifying immediate and basic or root causes – human, technical and organizational factors,
- Determining the preventive and corrective actions to avoid similar situations or occurrences,
- Establishing trends in accident/incident causes,
- Establishing training needs,
- Identifying new hazards and assessing the risks,
- Making recommendations to reduce or eliminate unacceptable risks, and
- Identifying lessons learned that should be shared with the employees and members
Open investigations not only help in creating a positive safety culture within the organization but also improves profitability by preventing losses caused by accidents.
8.4 Audit Findings and Follow Up
All records of internal audits shall be maintained.
The results of the audit shall be brought to the knowledge of the concerned person who shall take appropriate corrective or preventive actions in consultation with the General Manager.
The Safety Officer shall maintain a record of non-conformities and observations and their status.
Procedure for Internal Audits and Follow-Up Actions
SM 9 - Safety Management Review
9.1 Responsibility and Applicability
- The Safety Officer, on behalf of the Management, is responsible for initiating and conducting the Safety Management Review.
- The members of the Safety Committee will meet to conduct the Review. In addition, one available ACFC member may also be invited to attend.
- The results of the review will be included in the minutes of the Management Meeting on Form SM-MR.
9.2 The Review
9.2.1 Interval and purpose
- The SMS shall be reviewed at intervals of not more than one year.
- The purpose of this review is to ensure the management system’s
- Continuing suitability,
- Adequacy,
- Effectiveness in satisfying regulatory requirements
- Effectiveness in satisfying ACFC’s policy and objectives and to assess opportunities for improvement.
9.2.2 Evaluation elements
The review shall evaluate the following minimum elements of the system:
- Considerations for updating the SMS in relation to changes in new regulations, operational and business demands, etc.
- Internal audit reports.
- Recommendations for improvement.
- Feedback from employees, members, visitors, authorities and other interested parties/stakeholders
- Process performance and conformity of operations
- Status of preventive and corrective actions and effectiveness
- Follow-up actions from previous management reviews.
- Analysis of incidents, accidents, and injuries.
- Safety Performance Indicators and Targets
- Performance of external service providers
- Adequacy of resources/equipment
- Staff/Member safety training needs analysis.
- Effectiveness of actions to address risks
9.2.3 Management Review Meeting Outputs
Output from the review shall include decisions and actions related to:
- Improvement of the effectiveness of the SMS and its processes
- Improvement of procedures, systems of work and operation methodologies
- Reducing risks related to safety and health
- Resource needs
9.2.4 Management Review Meeting Agenda
- Minutes of the last meeting
- Adequacy of manpower and other resources
- Organisation set up
- Effectiveness of the Safety Management System
- New regulations and market demands
- Internal and External audit reports, findings and follow up
- Review of feedback from employees, members, visitors,
authorities and other interested parties/stakeholders - Process conformity and effectiveness of record keeping
- Review of Risk Assessment – existing controls
- Safety Performance Targets – status and reasons for not achieving the set targets
- Investigations – effectiveness of preventive and corrective actions
- Other Safety related matters
- Other Operational issues
9.3 Management Review Records
A record of all such reviews shall be maintained.
The record of the review shall include but not be limited to:
- The review team members
- Date of review
- Items reviewed
- Results of the review with action points
- Status of previous items or actions
- Conclusion
SM 10 - Process, Document & Data Control
10.1 Safety Manual (SM)
- Any member or employee using this manual may recommend to the Safety Officer or the General Manager, changes, amendments or modifications to the Safety Manual. After due deliberation and if considered valid, the recommended changes shall thereafter be incorporated into the SM.
- The Safety Officer, in consultation with the General Manager, is solely responsible for the administration, review and amendment of this SM.
- No other person is authorised to make any revision, alteration, or changes to the SM.
- The SM shall be reviewed at least once a year.
- SM Data Control:
- This manual is maintained up to date by the issue of modifications or revisions to the existing sections, pages or by the issue of additional pages in the respective sections of the manual.
- Whenever any additions or revisions are introduced in this manual, a revised list of contents, record of changes and a memo is issued.
- Revisions are indicated by a vertical side bar in the left-hand side margin.
- On receipt of the revised or additional pages and the revised list of contents, corresponding pages in the manual are replaced as directed in the memo. The obsolete pages shall be promptly removed and destroyed.
- The date on the list of content sheets SM-1 shall always indicate the status of the manual.
10.1.1
The Safety Manual is a controlled document and copies of this manual are not for distribution outside the Club.
The nomenclature and distribution of the controlled copies is as follows:
Controlled Copy # 01 – General Manager
Controlled Copy # 02 – Safety Officer (Training Room)
Controlled Copy # 03 – Admin OIC (Administration Office)
The Master Copy of this Safety Manual and all subsequent revisions will be first hosted on the ACFC SMS website and will remain the absolute source for the latest information.
The Safety Officer shall ensure that the printed controlled copies are updated soon after the online version is updated.
10.2 Managing Changes
The ACFC has a documented routine in place to manage changes to the Club, processes, and operations in a way that the safety of the services or operations are not negatively affected.
Types of changes, which may require a management of change procedure include but may not be limited to the following:
- Replacement of or hire of key personnel
- Changes in the organizational structure
- New equipment or alterations in existing equipment or machinery
- Installation of new instruments or equipment in aircrafts affecting pilot competency and training needs
- Addition of a new category or type of aircraft to the fleet
- Major changes to flight operation procedures or air traffic control
- Major changes to Club operation procedures
- Business improvements or expansion that impact safety
- Changes brought about by new legal or regulatory requirements
- Changes in the Security environment
- Changes to the operating environment, caused by the onset of a pandemic, natural disaster, abnormal weather phenomenon or social/political upheavals.
Procedure:
1. Proposal
The proposer can be any employee or member. The proposal for change is submitted to the General Manager or Safety Officer using Form SM-MOC.
- The required or proposed change will first be accurately defined including who and what it will affect.
- A formal risk assessment shall then be carried out to identify and control potential hazards, hazardous occurrences, substandard situations, or non-conformities with the existing safety system that may emerge because of the proposed change. This risk assessment will be recorded in Form SM-MOC.
2. Validation and Approval:
The General Manager or Safety Officer,
- reviews the change,
- checks for new risks that may have been introduced by the proposed change,
- develops an action plan, describing how the change will be implemented and assigns responsibilities,
- validates the proposal, and then approves the change on Form SM-MOC.
3. Implementation, Communication and Verification:
The proposer or Safety officer implements the change. The General Manager or Safety Officer communicates the change using Form SM-NMC or via E-Mail. The Safety Officer or the General Manager monitors the implementation and effectiveness of the change. All stages of implementation, communication and verification are summarized in Form SM-MOC.
10.3 Document and Data Control
1. The Safety Officer is responsible for the review and approval of all controlled documents prior to their issue. No other person is authorised to make any revision, alteration or changes to any form or document.
2.a. Controlled documents used in this SMS can be identified by a control header containing the following information:
- Identification of document
- Date of issue (revision date)
- Revision Number
- Initials of person who has prepared the document and responsible for the subsequent upkeep
- Initials of the person who has approved the document for use.
2.b. Controlled documents like forms, safety cards, safety posters and such similar media, used to support the SMS are identified by a control footer containing the following information:
- Identification of document
- Revision number and/or Revision date
3. Pertinent and current issues of relevant documents shall be available at points of usage. Invalid and/or obsolete documents/data shall be promptly removed from all points of issue or use to prevent unintended use.
4. The information regarding any change shall be disseminated within the Club either by using Form SM – NMC or by means of electronic mail.
Copies of E-mails or acknowledged N-MOC forms shall be held in an electronic format and archived for future reference.
10.3.1 Master List – Documents
A master list of all controlled forms and documents is maintained in Appendix 1 to this manual.
(Note: The Appendix is controlled and maintained independently of the Safety Manual)
SM 11 - Continual Improvement of the SMS
ACFC monitors and assesses the SMS processes to maintain and continually improve the overall effectiveness of the SMS. This is achieved by monitoring and controlling the following individual components of the SMS:
11.1 Safety Manual (SM)
- The Safety Officer, in consultation with the General Manager, administers, reviews, and amends the SM to guarantee that it contains up to date and relevant information to ensure its effectiveness.
- The SM is reviewed at least once a year.
11.2 Safety and Cultural Surveys
The ACFC conducts surveys including cultural surveys which provide useful feedback on the level of engagement of employees and members with the SMS. These surveys also provide indicators of the safety culture of the Club.
11.3 Safety Inspections and Safety Committee Meetings
- The Safety Officer conducts monthly inspections of the operational areas of the Club which besides indicating the actual condition of various areas and processes, including human behaviors, offer opportunities for improving existing systems.
- A monthly safety meeting of the Safety Committee, which discusses amongst other items the SPIs and areas and opportunities for improvement of the SMS.
11.4 Management Reviews
The ACFC conducts an annual review of the entire SMS to examine whether the safety performance objectives are being achieved. Since, the evaluation of the SPIs and SPTs is part of this review, it indicates trends and provides an opportunity for a gap-analysis and thus an opportunity to improve the existing system.
11.5 Internal Audits
Procedures have been established to carry out internal audits of the ACFC to verify the implementation of the SMS and to determine its effectiveness and assist in the decision-making process.
The audits are conducted against the Safety Management System described in this Safety Manual to verify compliance and identify opportunities for improvement.
SM 12 - Safety Promotion
ACFC endeavours to achieve the safety objectives and encourages the development and maintenance of a positive safety culture by providing a value system through continual education and training, maintaining clear and effective lines of communication and an active system of information-sharing. It is acknowledged that the safety promotion activity is an ongoing process and thus shall not be limited to the initial implementation phase. This is achieved by monitoring and controlling the following individual components of the SMS:
12.1 Safety Education and Training
ACFC maintains a safety training programme that ensures that key personnel are trained and competent to perform their SMS duties.
The Safety Officer, in consultation with the General Manager, is responsible for ensuring that there is a suitable training programme in place and operational. The programme includes both initial and recurrent training requirements.
- The initial safety training program includes the following:
- ACFC’s safety policies and safety objectives
- Roles and responsibilities related to safety
- Basic SRM principles
- Safety reporting systems
- SMS processes and procedures and
- Human factors
- The recurrent safety training programme includes the following:
- Changes to the SMS policies and objectives
- Changes in procedures and processes
- Lessons learned from events and specific safety issues
12.2 Safety Communication
The ACFC employs one or more of the following methods to ensure that safety information is effectively delivered to those personnel directly involved in the operation of the SMS and to the other employees and members:
- Notices
- Bulletins
- Posters
- Safety cards
- Briefings
- Training courses
- Email and other electronic media
The effectiveness of the above methods shall be assessed during internal audits and safety inspections and required changes made to ensure that the most efficient and effective means are employed for promoting safety. The aim of effective safety communication is:
- Ensuring SMS awareness
- Dissemination of safety-critical information
- Raising awareness of new risk controls
- Providing information on new or amended procedures
- Promotion of a positive safety culture
- Providing feedback on actions taken to address safety concerns
