Implementation process of EASA Management system

in Adria Tehnika d.o.o.

Vransko, Dec 2022

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ICAO
In Aviation,
Safety is FIRST!

Safety is
EVERYBODY‘S
responsibility!
1. HISTORY (i.e. WHY?)
 Fact’s

 Why SMS?

 Regulation (ICAO SMS/EASA Management System)

 Preparation of the process

 Presentation to the Management

 Nomination of Safety Manager

FACT’s

Most ATA - chapter breakdown

1. place: ATA 25 (Equip & furnishning)

2. place: ATA 71-80 (Combined powerplant)
3. place: ATA 32 (Landing gear)
4. place: ATA 27 (Flight controls)

80% of maintenance errors involve human factors!

FACT’s

Can we control everything?

 WHY

• ICAO Safety Management System & EASA Management System,

• EASA pipeline for Part-145 organization implementation for years,

• EASA latest NPA 2019-05 (C) served pre-final requirements,

• Commission Implementing Regulation (EU) 2021/1963 of 8 Nov 2021 amending gives final implementation date as of Dec 02,
2022 for Management system in Part-145 AMO’s.
WHY

BETTER!
BETTER!
IMPROVED
IMPROVED

BETTER!
FASTER!
IMPROVED

IMPROVED
IMPROVED

IMPROVED
MORE EFFICIENT!
IMPROVED
REGULATION
PREPARATION, PRESENTATION TO MANAGEMENT

Performance of initial calculation, process, numbers… Meeting with the management

GO!
NOMINATION OF SAFETY MANAGER

Initial Training (ICAO / EASA Management System)

Amsterdam!


  The Manual

 Gap analysis & implementation plan

 Nominated personnel & duties

2. TODAY  Initial training of all personnel

 Publication access

 SAG meetings, SRB

 Reporting, Just culture, Safety Risk Management

 Error investigation process

 Hazard ID, Hazard & Risk register log

 Risk assessment example

 Safety Communication: Safety Directives, Notes

 Feedback & safety promotion

 Emergency response plan (ERP)

 Management of change

 Compliance monitoring, audits

 Struggles and challenges

THE MANUAL

New revision shortly!

GAP ANALYSIS & IMPLEMENTATION PLAN
NOMINATED PERSONNEL & DUTIES
INITIAL TRAINING OF ALL PERSONNEL
PUBLICATION ACCESS
SAG MEETINGS
SRB MEETINGS
REPORTING

"Just Safety Culture" is a combination of four complementary

cultures:

• An “Informative” culture, which requires the management

of all systems to have a positive knowledge view
concerning human, technical, organizational, and
environmental factors with impact/contribute to the
organization, allowing for errors to occur.
• A “Flexible” culture is open for changes based on
“learning from experiences” and solid safety culture with
priorities on SAFETY.
• A “Reporting” culture is based on an open organizational
climate where all involved are encouraged to report all
occurrences deviating from known standards and
requirements, hazards, and errors without any retribution.
• A “Learning” culture willing to perform proactive and
corrective actions, and take appropriate action and
decisions based on conclusions from relevant information.
Willing to implement major reforms where deemed
necessary.
JUST CULTURE PRINCIPLES

“An atmosphere, where of trust in which people are encourage

(or in some cases even rewarded) for providing essential
safety-related information, but in which they are also clear
about where the must be drawn between acceptable and
unacceptable behaviour.”

In order to encourage reporting of occurrences in Adria Tehnika

not only reporters but also persons mentioned in the occurrence
reports concerned, are protected.
Every maintenance organization should have some formal means of reporting all items to designated departments for any known
reason. Reporting should be established in a simplest manner possible to allow staff quick and hassle free reporting.

In Adria Tehnika all of reporting items starts with Initial Event Report Form (DNA Form-2 or accessible in E-Manuals for all staff).
Sample and instructions as follows:
The number of reports in the ECR steadily increased from 2016 to 2019, with the figure for 2019 being 50% higher than for 2016. By contrast, the
level of traffic in Europe increased at a slower pace, with +8% of airport movements in 2019 compared to 2016. The overall reporting rate
therefore increased over this period from 15.4 to 21.2 reports per 1 000 airport movements.

In 2020, the COVID-19 pandemic caused a drastic decrease in the level of traffic, which then recovered only partially in 2021. The total number
of reports also dropped substantially in 2020, but this drop was less pronounced than the drop in traffic. Also, in 2021, the number of reports
increased rapidly compared to 2020, reaching back the volumes reported in 2017. Consequently, the overall reporting rate continued to
increase significantly over the last 2 years, to reach 32.5 reports/1000 airport movements, which is doubled compared to 2016.
SAFETY RISK MANAGEMENT

https://www.easa.europa.eu/domains/safety-management/safety-risk-management
ERROR INVESTIGATION PROCESS

Since the introduction of MEDA by Boeing, a growing number of related maintenance organizations have also adopted MEDA; a
tool for investigating the factors that lead to an error, and making suggested improvements to reduce the likelihood of future
errors.
HAZARD IDENTIFICATION

The objective of hazard identification is to identify those hazards which

either currently exist and can cause an immediate problem or may pose
potential hazards in the future. A hazard can be considered a latent error or
threat that has some level of risk associated with it.

"A hazard is any existing or potential condition that can lead to injury, illness, or
death to people; damage to or loss of a system, equipment, or property; or
damage to the environment."

Hazards may be classified:

• PHYSICAL (MOUNTAINS, OBSTACLES)

• HUMAN BEHAVIORS
• POLITICAL
• ENVIRONMENTAL (WEATHER)
• LEGAL
• TECHNOLOGICAL
The following safety management methods are used for the
identification of hazards:

REACTIVE:
o review and analyses event/incident/accident, review
maintenance errors, reports, and complaints,
audits, determination of contributory factors and findings as
to risks,

PROACTIVE:
o mandatory and voluntary reporting systems, safety audits and
surveys,

PREDICTIVE:
o authority feedback, information-exchange practices with
similar organizations, confidential reporting system, normal
maintenance operation monitoring.

A mountain is a HAZARD.
HAZARD

RISK
Running into the mountain and causing
mission failure is the RISK
HAZARD & RISK REGISTER LOG
RISK MODULE PROCESS
RISK ASSESSMENT EXAMPLE
SAFETY DIRECTIVE EXAMPLE
RISK ASSESSMENT EXAMPLE
SAFETY NOTE EXAMPLE
SAFETY HAZARD EXAMPLE
SAFETY HAZARD EXAMPLE

FOLLOW-UP:
FEEDBACK AND SAFETY PROMOTION

As we obtain informations, data and first input from several sources, picture found below represent all the links, paths for Compliance department
with necessary informations and provisional inputs:

AUDITS
TC BULLETIN’S
STC BULLETIN’S

SAFETY REPORTS
VOLUNTARY REPORTS

ADVISERY NOTES

EVENT REPORTS

FEEDBACK INSPECTIONS

CUSTOMER’S REPORTS AD & SB NOTES

INTERNAL AUDITS CONFIDENTIAL REPORTS BULLETINS

TRAINING AND EDUCATION

All staff will receive safety training as appropriate for their safety responsibilities. In particular, all managers and operational
personnel will be trained and be competent to perform their SMS duties. There are four major reasons why training is needed:

 Required by Law - Certain training is required by our governing organizations.

 Hazards in Our Workplace - We must identify hazards in our company. These hazards are found in all the systems of the
organization.
 Dangerous Work Practices On the Job - Observations may reveal actions and practices in our workplace that pose danger to
some individuals.
 Introduction of New Equipment or Procedures - Training should be provided whenever new equipment is introduced or
changes are made to your operations.

FREQUENCY OF TRAINING

TYPE OF TRAINING AFFECTED PERSONNEL

Initial Continuation

Advance SMS Training

Safety Manager X every 5 years
(external training)

SMS Training (in-house) Quality & Safety auditors X every 5 years

SMS Training (in-house) All employees X

Hazard reporting & Risk every 2 years

Maintenance, Engineering
Management (Safety X
Managers ( & deputies)
Promotion)

Human Factors (in-house) All employees X

EMERGENCY RESPONSE PLAN (ERP)
AT Accountable manager is responsible for assuring that all personnel is
trained to handle organization emergencies based on their role in the
organization.
DOCUMENTATION

• One of the most important issues when dealing with the development and
implementation of a safety management system is the accurate recording
of all processes and procedures in the form of instructions and policy
documents. Linked to this it is vital that all training carried out is recorded
for inspection or audit

• All safety documents are controlled through the AT DNA software system.
Change control procedures are incorporated into the manual.

• The Safety Manager is responsible for maintaining safety-related data,

including the minutes of safety meetings, information on hazard and risk
analysis, risk management, remedial action, incident and accident
investigations, trend files, and audit reports.

• All records of management system key processes in reference to 145.A.200

is retained for minimum period of 5 years.
MANAGEMENT OF CHANGE

Unless properly managed, changes in organizational structure, personnel, documentation, processes, or procedures can result in the
inadvertent introduction of hazards and increased risk.The systematic approach to managing and monitoring organizational change
is part of risk management.
When a major change in operations, equipment, or services is anticipated, a process will be used which will include hazard
identification and risk assessment. Management of change requires a team approach and all personnel should have the
opportunity to provide input when changes could have implications to health and/or safety. Process for managing change has 4
basic phases: screening, review, approval, and implementation. Both the effect of change and the effect of implementing change
is considered.
COMPLIANCE MONITORING, AUDITS
CHALLENGES, STRUGGLES

 Step 1: Present idea to Management

 Get “the big picture”

 Initial training

 Understand the basics

 Access to documentation, cases, examples

 Building up the Manual, Forms

 Setting up the process

 Initial Training for all staff

 Baby steps

 Implement changes ICAO SMS vs EASA Management System

 We start today – 02.Dec 2022

3. FUTURE
 Regulation compliance

 Statistics, SPI’s, Trend Analysis

 Safety Communication

 Continous improvement of the Management system

REGULATION COMPLIANCE

 https://www.caa.si/

 https://www.easa.europa.eu/en/home

 https://www.airsafety.aero/Special-Pages/Search.aspx?searchtext=otar&searchmode=anyword

 https://www.caa.co.uk/

 …
BOW TIE DIAGRAM

Construction of a Bow Tie diagram involves asking a structured

set of questions:

• What is the hazard?

• What happens when hazard control is lost?
• What safety event (threat) could release the hazard?
• What are the potential outcomes?
• How can we avoid the undesired/hazardous event?
• How can we recover if the event occurs? How can the potential
outcome likelihood or
• consequence severity be limited?
• How might controls fail? How could their effectiveness become
undermined?
• How do we make sure that controls do not fail?
SAFETY PERFORMANCE INDICATIORS (SPI’S), TREND ANALYSIS

SPI’s are developed for means to verify the safety performance of the organization and to validate the
effectiveness of safety risk controls in reference to safety performance indicators and safety performance targets
of the SMS.

Safety performance indicators are data-based parameters, that are used for monitoring & assessing the safety
performance within the organisation. They measure certain characteristics about occurrences, events, incidents,
accidents, hazards….

Safety performance targets (SPT) are planned objective for SPI's over a season period in sources that organisation
uses for obtaining and setting the SPI's:

REACTIVE MOR, IER, CIR, Hazard ID, Safety Investigations....

PROACTIVE Audits, surveys, Compliance Monitoring, plans...

PREDICTIVE Processes monitoring, Trend following, Statistical analysis

 Trend analysis

 Raise?

 Fall?

 Remains the same?

 Make realistic prediction for future

 In case of raise, need to plane the necessary actions

SAFETY COMMUNICATION

Staff with DNA access Staff without DNA access

CONTINOUS IMPROVEMENT OF THE MANAGEMENT SYSTEM

Continuous improvement in safety is a “core value.” This is accomplished by measuring safety performance and
implementing necessary changes. In addition, we will ensure the following to continually improve our organization:

• Increase the submission of Hazard Reports

• Increase the number of actions raised by safety meetings

• Track improvements made to work procedures

• Increase compliance with the safety incident management process (reporting, classification, root cause
investigation, and implementation of corrective actions)

• Reduce the number of non-compliances with standard maintenance procedures as measured by observation.

The Safety Manager is responsible for ensuring organization performance is annually reviewed. The results of all
safety performance monitoring will be documented by the Safety Manager and used as feedback to improve the
system. The report of the accomplishments and/or deficiencies will be discussed during the scheduled Safety
Review Board meetings.
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