SMS GAP ANALYSIS CHECKLIST AND IMPLEMENTATION PLAN

Ref: ICAO Safety Management Implementation Website (October 2017)

1.    INITIAL GAP ANALYSIS CHECKLIST (TABLE 1)

1.1 The initial gap analysis checklist in Table 1 can be used as a template to conduct the first step of an
SMS gap analysis. This format with its overall “Yes/No/Partial” responses will provide an initial indication of the
broad scope of gaps and hence overall workload to be expected. The questionnaire may be adjusted to suit the
needs of the organization and the nature of the product or service provided. This initial information should be
useful to senior management in anticipating the scale of the SMS implementation effort and hence the resources
to be provided. This initial checklist would need to be followed up by an appropriate implementation plan as per
Tables 2 and 3.

1.2. A “Yes” answer indicates that the organization meets or exceeds the expectation of the question
concerned. A “No” answer indicates a substantial gap in the existing system with respect to the question’s
expectation. A “Partial” answer indicates that further enhancement or development work is required to an existing
process in order to meet the question’s expectations.

Table 1.    Gap analysis checklist

SMM 4th State Status of

Aspect to be analysed or question to be edition regulations implementatio
No. answered reference reference Answer n
Component 1 — SAFETY POLICY AND OBJECTIVES
Element 1.1 — Management commitment
1.1-1 Is there a safety policy in place? ¨ Yes
¨ No
¨ Partial

1.1-2 Does the safety policy reflect senior ¨ Yes

management’s commitment regarding safety ¨ No
management? ¨ Partial

1.1-3 Is the safety policy appropriate to the size, nature ¨ Yes

and complexity of the organization? ¨ No
¨ Partial

1.1-4 Is the safety policy relevant to aviation safety? ¨ Yes

¨ No
¨ Partial

1.1-5 Is the safety policy signed by the accountable ¨ Yes

executive? ¨ No
¨ Partial

1.1-6 Is the safety policy communicated, with visible ¨ Yes

endorsement, throughout the [Organization]? ¨ No
¨ Partial

1.1-7 Is the safety policy periodically reviewed to ¨ Yes

ensure it remains relevant and appropriate to the ¨ No
[Organization]? ¨ Partial
Element 1.2 — Safety accountability and responsibilities
 SMM 4th State Status of
Aspect to be analysed or question to be edition regulations implementatio
No. answered reference reference Answer n

1.2-1 Has [Organization] identified an accountable ¨ Yes

executive who, irrespective of other functions, ¨ No
shall have ultimate accountability, on behalf of ¨ Partial
the [Organization], for the implementation and
maintenance of an effective SMS?

1.2-2 Does the accountable executive have full control ¨ Yes

of the financial and human resources required for ¨ No
the operations authorized to be conducted under ¨ Partial
the operations certificate?

1.2-3 Does the Accountable Executive have final ¨ Yes

authority over all aviation activities of his ¨ No
organization? ¨ Partial

1.2-4 Has [Organization] identified and documented ¨ Yes

the safety accountabilities of management as ¨ No
well as operational personnel, with respect to the ¨ Partial
SMS?

1.2-5 Is there a safety committee or review board for ¨ Yes

the purpose of reviewing SMS and safety ¨ No
performance? ¨ Partial

1.2-6 Is the safety committee chaired by the ¨ Yes

accountable executive or by an appropriately ¨ No
assigned deputy, duly substantiated in the SMS ¨ Partial
manual?

1.2-7 Does the safety committee include relevant ¨ Yes

operational or departmental heads as ¨ No
applicable? ¨ Partial

1.2-8 Are there safety action groups that work in ¨ Yes

conjunction with the safety committee (especially ¨ No
for large/complex organizations)? ¨ Partial
Element 1.3 — Appointment of key safety personnel
1.3-1 Has [Organization] appointed a qualified person ¨ Yes
to manage and oversee the day-to-day operation ¨ No
of the SMS? ¨ Partial

1.3-2 Does the qualified person have direct access or ¨ Yes

reporting to the accountable executive ¨ No
concerning the implementation and operation of ¨ Partial
the SMS?

1.3-3 Does the manager responsible for administering ¨ Yes

the SMS hold other responsibilities that may ¨ No
conflict or impair his role as SMS manager? ¨ Partial

1.3-4 Is the SMS manager’s position a senior ¨ Yes

management position not lower than or ¨ No
subservient to other operational or production ¨ Partial
positions?
Element 1.4 — Coordination of emergency response planning
 SMM 4th State Status of
Aspect to be analysed or question to be edition regulations implementatio
No. answered reference reference Answer n

1.4-1 Does [Organization] have an emergency ¨ Yes

response/contingency plan appropriate to the ¨ No
size, nature and complexity of the organization? ¨ Partial

1.4-2 Does the emergency/contingency plan address ¨ Yes

all possible or likely emergency/crisis scenarios ¨ No
relating to the organization’s aviation product or ¨ Partial
service deliveries?

1.4-3 Does the ERP include procedures for the ¨ Yes

continuing safe production, delivery or support of ¨ No
its aviation products or services during such ¨ Partial
emergencies or contingencies?

1.4-4 Is there a plan and record for drills or exercises ¨ Yes

with respect to the ERP? ¨ No
¨ Partial

1.4-5 Does the ERP address the necessary ¨ Yes

coordination of its emergency ¨ No
response/contingency procedures with the ¨ Partial
emergency/response contingency procedures of
other organizations where applicable?

1.4-6 Does [Organization] have a process to distribute ¨ Yes

and communicate the ERP to all relevant ¨ No
personnel, including relevant external ¨ Partial
organizations?

1.4-7 Is there a procedure for periodic review of the ¨ Yes

ERP to ensure its continuing relevance and ¨ No
effectiveness? ¨ Partial
Element 1.5 — SMS documentation
1.5-1 Is there a top-level SMS summary or exposition ¨ Yes
document which is approved by the accountable ¨ No
manager and accepted by the CAA? ¨ Partial
[5.3.36 to 5.3.38]

1.5-2 Does the SMS documentation address the ¨ Yes

organization’s SMS and its associated ¨ No
components and elements? ¨ Partial

1.5-3 Is [Organization] SMS framework in alignment ¨ Yes

with the regulatory SMS framework? ¨ No
¨ Partial

1.5-4 Does [Organization] maintain a record of relevant ¨ Yes

supporting documentation pertinent to the ¨ No
implementation and operation of the SMS? ¨ Partial

1.5-5 Does [Organization] have an SMS ¨ Yes

implementation plan to establish its SMS ¨ No
implementation process, including specific tasks ¨ Partial
and their relevant implementation milestones?

1.5-6 Does the SMS implementation plan address the ¨ Yes

 SMM 4th State Status of
Aspect to be analysed or question to be edition regulations implementatio
No. answered reference reference Answer n

coordination between the service provider’s SMS ¨ No

and the SMS of external organizations where ¨ Partial
applicable?

1.5-7 Is the SMS implementation plan endorsed by the ¨ Yes

accountable executive? ¨ No
¨ Partial
Component 2 — SAFETY RISK MANAGEMENT
Element 2.1 — Hazard identification
2.1-1 Is there a process for voluntary hazards/threats ¨ Yes
reporting by all employees? ¨ No
¨ Partial

2.1-2 Is the voluntary hazard/threats reporting simple, ¨ Yes

available to all personnel involved in safety- ¨ No
related duties and commensurate with the size of ¨ Partial
the service provider?

2.1-3 Does [Organization] SDCPS include procedures ¨ Yes

for incident/accident reporting by operational or ¨ No
production personnel? ¨ Partial

2.1-4 Is incident/accident reporting simple, accessible ¨ Yes

to all personnel involved in safety-related duties ¨ No
and commensurate with the size of the service ¨ Partial
provider?

2.1-5 Does [Organization] have procedures for ¨ Yes

investigation of all reported incident/accidents? ¨ No
¨ Partial

2.1-6 Are there procedures to ensure that ¨ Yes

hazards/threats identified or uncovered during ¨ No
incident/accident investigation processes are ¨ Partial
appropriately accounted for and integrated into
the organization’s hazard collection and risk
mitigation procedure?

2.1-7 Are there procedures to review hazards/threats ¨ Yes

from relevant industry reports for follow-up ¨ No
actions or risk evaluation where applicable? ¨ Partial
Element 2.2 — Safety risk assessment and mitigation
2.2-1 Is there a documented hazard identification and ¨ Yes
risk mitigation (HIRM) procedure involving the ¨ No
use of objective risk analysis tools? ¨ Partial

2.2-2 Is the risk assessment reports approved by ¨ Yes

departmental managers or at a higher level ¨ No
where appropriate? ¨ Partial

2.2-3 Is there a procedure for periodic review of ¨ Yes

existing risk mitigation records? ¨ No
¨ Partial

2.2-4 Is there a procedure to account for mitigation ¨ Yes

 SMM 4th State Status of
Aspect to be analysed or question to be edition regulations implementatio
No. answered reference reference Answer n

actions whenever unacceptable risk levels are ¨ No

identified? ¨ Partial

2.2-5 Is there a procedure to prioritize identified ¨ Yes

hazards for risk mitigation actions? ¨ No
¨ Partial

2.2-6 Is there a programme for systematic and ¨ Yes

progressive review of all aviation safety-related ¨ No
operations, processes, facilities and equipment ¨ Partial
subject to the HIRM process as identified by the
organization?
Component 3 — SAFETY ASSURANCE
Element 3.1 — Safety performance monitoring and measurement
3.1-1 Are there identified safety performance indicators ¨ Yes
for measuring and monitoring the safety ¨ No
performance of the organization’s aviation ¨ Partial
activities?

3.1-2 Are the safety performance indicators relevant to ¨ Yes

the organization’s safety policy as well as ¨ No
management’s high-level safety ¨ Partial
objectives/goals?

3.1-3 Do the safety performance indicators include ¨ Yes

alert/target settings to define unacceptable ¨ No
performance regions and planned improvement ¨ Partial
goals?

3.1-4 Is the setting of alert levels or out-of-control ¨ Yes

criteria based on objective safety metrics ¨ No
principles? ¨ Partial

3.1-5 Do the safety performance indicators include ¨ Yes

quantitative monitoring of high-consequence ¨ No
safety outcomes (e.g. accident and serious ¨ Partial
incident rates) as well as lower-consequence
events (e.g. rate of non-compliance, deviations)?

3.1-6 Are safety performance indicators and their ¨ Yes

associated performance settings developed in ¨ No
consultation with, and subject to, the civil aviation ¨ Partial
authority’s agreement?

3.1-7 Is there a procedure for corrective or follow-up ¨ Yes

action to be taken when targets are not achieved ¨ No
and alert levels are exceeded/ breached? ¨ Partial

3.1-8 Are the safety performance indicators ¨ Yes

periodically reviewed? ¨ No
¨ Partial
Element 3.2 — The management of change
3.2-1 Is there a procedure for review of relevant ¨ Yes
existing aviation safety-related facilities and ¨ No
equipment (including HIRM records) whenever ¨ Partial
 SMM 4th State Status of
Aspect to be analysed or question to be edition regulations implementatio
No. answered reference reference Answer n

there are pertinent changes to those facilities or

equipment?

3.2-2 Is there a procedure for review of relevant ¨ Yes

existing aviation safety-related operations and ¨ No
processes (including any HIRM records) ¨ Partial
whenever there are pertinent changes to those
operations or processes?

3.2-3 Is there a procedure for review of new aviation ¨ Yes

safety-related operations and processes for ¨ No
hazards/risks before they are commissioned? ¨ Partial

3.2-4 Is there a procedure for review of relevant existing ¨ Yes

facilities, equipment, operations or processes ¨ No
(including HIRM records) whenever there are ¨ Partial
pertinent changes external to the organization
such as regulatory/industry standards, best
practices or technology?
Element 3.3 — Continuous improvement of the SMS
3.3-1 Is there a procedure for periodic internal ¨ Yes
audit/assessment of the SMS? ¨ No
¨ Partial

3.3-2 Is there a current internal SMS audit/assessment ¨ Yes

plan? ¨ No
¨ Partial

3.3-3 Does the SMS audit plan include the sampling of ¨ Yes
completed/existing safety risk assessments? ¨ No
¨ Partial

3.3-4 Does the SMS audit plan include the sampling of ¨ Yes
safety performance indicators for data currency ¨ No
and their target/alert settings performance? ¨ Partial

3.3-5 Does the SMS audit plan cover the SMS ¨ Yes
interface with subcontractors or customers where ¨ No
applicable? ¨ Partial

3.3-6 Is there a process for SMS audit/assessment ¨ Yes

reports to be submitted or highlighted for the ¨ No
accountable manager’s attention where ¨ Partial
appropriate?
Note.— The references to the SMM 4th edition in the third column will be provided once the document is finalized
and published.
 2.    DETAILED SMS GAP ANALYSIS AND IMPLEMENTATION TASKS (TABLE 2)

The initial gap analysis checklist in Table 1 should then be followed up by using the detailed “SMS gap analysis
and implementation task identification plan” in Table 2. Once completed, Table 2 will provide follow-up analysis
on details of the gaps and help translate these into actual required tasks and subtasks in the specific context of
the organization’s processes and procedures. Each task will then accordingly be assigned to appropriate
individuals or groups for action. It is important that correlation of individual element/task development with their
descriptive placeholders in the SMS document be provided for in Table 2 in order to trigger progressive updating
of the draft SMS document as each element is implemented or enhanced. (Initial element write-ups in SMS
documents tend to be anticipatory rather than declaratory.)

3.    ACTIONS/TASKS IMPLEMENTATION SCHEDULE (TABLE 3)

Table 3 will show the milestones (start-end dates) scheduled for each task/action. For a phased implementation
approach, these tasks/actions will need to be sorted according to the phase allocation of their related elements.
Table 3 can be a separate consolidation of all outstanding actions/tasks or, if preferred, be a continuation of
Table 2 in the form of a spreadsheet. Where it is anticipated that the actual number of tasks/actions and their
milestones are sufficiently voluminous and complex so as to require utilizing a project management software to
manage them, this may be done by using software such as MS project/Gantt chart as appropriate. Table 4 is an
illustration of a Gantt chart.
 Table 2.    Example SMS gap analysis and implementation task identification plan

Status of
Answer Assigned SMS action/task
Questio (Yes/No/Partial Action/task required task document (Open/WIP/Closed
n Ref # Gap analysis question ) Description of gap to fill the gap group/person reference )
1.1-1 Is there a safety policy Partial The existing safety a) enhance the Task Chapter 1, Open
in place? policy addresses existing safety Group 1 Section 1.3.
OSHE only. policy to include
aviation SMS
objectives and
policies or develop
a separate aviation
safety policy;

b) have the safety

policy approved
and signed by the
accountable
executive.
etc.
 Table 3.    Example SMS implementation schedule

Assigned Status Schedule/timeline

Action/task required SMS task of
to fill the gap document group/ action/ 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q 1Q 2Q 3Q 4Q
ref. person task 17 17 17 17 18 18 18 18 19 19 19 19 etc.
1.1-1 a) Enhance the existing Chapter 1, Task Open
safety policy to include Section 1.3. Group 1
aviation SMS objectives
and policies or develop a
separate aviation safety
policy.
1.1-1 b) Require the safety policy
to be approved and
signed by the
accountable executive.
etc.
Table 4.    Sample SMS implementation schedule (Gantt chart)

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