Lessons Learned from Airport Safety Management Systems Pilot Studies (2012)

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54 TP 13881, Revision 1, dated 2002-03-01, Safety Man- agement Systems for Flight Operations and Aircraft Maintenance Organizations. • 2004: Published Safety Management Systems for Small Aviation Operations—A Practical Guide to Implemen- tation (TP 14135). • 2004: Safety Management Systems: Transport Cana- da’s Implementation Plan (TC website 2011). SAFETY MANAGEMENT SYSTEM IMPLEMENTATION IN CANADA Unlike the U.S. airports participating in Studies 1 and 2 that developed all four components of the SMS simultane- ously, Transport Canada used a phased project approach, which developed program aspects sequentially building on and testing each phase within a 3-year period. Canadian airports began development of their SMS program in a four-phase approach beginning in 2005 with the following milestones. For large airports (such as the airports interviewed) [CAR 302.500 (1)], SMS implementation milestone dates included the following: 1. Before March 31, 2008, a. Ensure that the accountable executive submits the signed statement required by CAR 106.02(1)(c); and b. Complete Phase I of the SMS implementation phases outlined in the Advisory Circular 300-002, Implementation Procedures for Safety Manage- ment Systems for Airport Operators. 2. Before March 31, 2009, correct any deficiencies in the project plan submitted as part of Phase I that have been identified by Transport Canada and complete Phase II of the SMS implementation phases. 3. Before March 31, 2010, complete Phase III of the SMS implementation phases in accordance with the project plan. 4. Before March 31, 2011, complete Phase IV of the SMS implementation program in accordance with the project plan. The four phases include: Phase I: Assignment of accountable executive, gap analy- sis, and project plan. Phase II: Development of the safety management plan, reactive processes, investigation and analysis, risk man- Although not a part of the FAA studies, administrators from three Canadian airports were interviewed (all Class I equivalents) using the same set of questions to guide the discussion. The Canadian airports were selected based on size, location, and SMS implementation status. In 2005, Transport Canada, which certifies and regulates all airports in Canada, initiated an aviation-wide SMS program. Cer- tain airports (with a certificate issued under Section 302.03) began implementation in 2008 and are in the final phases of SMS implementation. Because U.S. airports are in the early stages of implementation, the Canadian airport per- spective (albeit a small survey group) was considered useful to provide a more thorough analysis of later stages within the implementation process. The three airports included: • Vancouver International Airport (YVR), Vancouver, Canada; • Edmonton International Airport (YEG), Alberta, Can- ada; and • Montréal–Mirabel International Airport (YUL), Mon- treal, Canada. The airports were interviewed using the same survey ques- tions as U.S. airports to maintain continuity. Questions relat- ing to FAA pilot studies or funding were modified or adjusted to address Canadian experiences. The survey information was not included in the broader survey assessment and is presented in this appendix as supplementary information. BACKGROUND Transport Canada (TC) is responsible for transportation policies and programs throughout Canada. TC’s oversight includes air, marine, road, and rail transportation. TC as an ICAO contracting state began the nation’s comprehensive SMS program in early 2000. The following list outlines SMS aviation development in Canada per the TC SMS website. • 2000–present: Development of Notice of Proposed Amendments (17 NPAs) and changes to the Aeronau- tics Act. • 2001: Published Introduction to Safety Management Systems (TP 13739). • 2001–2004: Educational Campaign on Concepts and Principles. • 2002: Published Safety Management Systems for Flight Operations and Aircraft Maintenance Organizations (TP 13881). Note: Advisory Circular 107-001 replaces APPENDIX A Canadian Interview Summary

55 agement, training for personnel assigned duties, and documented policies and procedures. Phase III: Deployment of proactive processes, documented policies and procedures, and training for personnel assigned duties. Phase IV: Quality assurance, emergency preparedness and response, training for personnel, and documented policies and procedures. All three of the airports interviewed had finished all four SMS phases; however, all had not completed an official TC audit at the time of the interviews. INTERVIEW FINDINGS AND OBSERVATIONS Because of the limited number of airport staff interviewed, graphs and charts were not developed; in its place a summary of key findings and observations from the interviews is pre- sented here by topics or SMS phase. Phase I Analysis and Preparatory Documentation Per the required SMS Phase I elements, all Canadian airports interviewed conducted a gap analysis and developed a project plan. When asked whether the gap analysis was useful, com- ments included that, when the gap analysis was conducted, the airside operations findings were nominal; however, the ability to document the findings in the gap analysis assisted with getting buy-in from upper management and including identifying resources and funding to support other aspects of the program, such as increased data collection and trending. Airports also commented that the gap analysis timeline was short and that a longer period would have helped with analy- sis and documentation. Canadian airports developed implementation plans as part of Phase I, but according to one airport, the airport team revised the plan annually as part of the ongoing program with the plan submitted in March, reviewed over the summer, and revised in the fall; this occurred each year. The initial plan developed was a blueprint, but as the program was rolled out, the plan changed to reflect new or revised aspects of the program. Phase II Safety Management Plan Airports began authoring the program manual (Safety Management Plan) as part of Phase II and used the outline provided by TC. If airports varied the contents, TC did not approve the manual and airports were required to revise or adjust the contents to align with the prescribed format. When asked whether the Safety Management Plan had been revised (either through TC review or internal changes), all airports commented that “yes” the Safety Management Plan had evolved either as a result of implementation, which required revisions to processes and procedures, or as a result of new advisory circulars and industry information. The initial docu- ments were considered the “backbone” of the program, but as the program progressed, there was a need to revise aspects such as the proactive investigation procedures, additional training, and reporting. One of the airports commented that it removed the “fluff” in the original document and focused on developing a very straightforward document that staff can pick up and easily use. Consultant Assistance and Resources All three Canadian airports interviewed stated they did not hire consultants to lead the development of the SMS program. Canadian airports did not receive funding or grants to imple- ment the program; costs were managed internally by each airport, which limited the opportunity in some cases to hire consultants. Two airports stated that they had enlisted experts in specific areas, such as training and human factors, but the program was led and managed internally. Additionally, Montreal reported that finding a bilingual consultant would have been challenging and thus the decision was made to develop the program in-house. Airports also commented that in the early days, TC and the airports were working closely on a regional basis and that bringing consultants from out- side (or not familiar with the airport or TC processes) would have limited the flexibility and continuous change needed to develop and refine the program as it evolved. TC provided a number of resources, references, guides, and templates for Canadian airports. When asked what other references Canadian airports used, responses included the ICAO SMM, the Australian Civil Aviation Safety Authority program, airline resources, Canadian Airport Council infor- mation, articles, and references from industry experts such as James Reason, and formal training programs. Staffing and Positions All three airports reported having both a safety manager and accountable executive in place. TC regulations require formal assignment of the accountable executive. For all, the safety manager (also referred to as accountable manager) position is a collateral duty and, as of the interview date, no additional positions have been added, although some are being considered for the future. Safety Policy As part of TC requirements, all airports stated that an approved safety policy is in place and has been rolled out to staff through initial SMS training. Airports also confirmed that safety policies have not been shared with tenants and, for some, the policy is focused only on airport staff; there- fore, tenants are not expected to comply. All airports reported

56 that policy objectives are in place and are being monitored through data tracking and trending and reviewed annually. Safety Risk Management Each airport surveyed indicated that it had conducted a number of safety risk assessments, including one airport that had con- ducted a complete hazardous inventory and assigned mitigations to multiple departments. Other topics included new equipment type (Airbus 380) operations, runway pavement replacement, construction programs, and airside vehicle program changes. Safety Assurance Under the TC requirements, all airports are required to implement reactive and proactive investigation and analysis processes and audit programs. Each airport reported that pro- active investigations, including training for staff, were under- way. Also airports stated that audit programs were completed or nearly finished and staff had completed internal audits and were scheduling external audits by the end of 2011. Data tracking and trending challenges include disparate systems and consolidation for reporting (manual processes), developing, and purchasing new systems and integrating reports, finding the right level of data to collect and analyze. In one case the airport reported that there are too much data and trending is difficult, but the annual audit program and review would assist in refining the process and reports. Safety Promotion—Culture and Training As part of the implementation and safety promotion aspects of the program, airports were asked if they encountered any safety culture challenges. Responses included staff complacency as a result of not seeing immediate benefits from the program and from delayed management support. Also reported was the lack of communication across departments to resolve collec- tive issues and the lack of top management buy-in. TC required structured training programs throughout Phases II, III, and IV; therefore, Canadian airports developed thorough and detailed training programs, including SMS overview, awareness training, reactive and proactive process training, how and why to report dangers and incidents, and human factors. Two airports have developed online courses in addition to in-class training programs. All airports reported training has been accomplished for the majority of internal staff over the past few years. Airports interviewed are not planning on offering training to tenants at this time, stating that most have their own training and that safety meetings and briefings are used to keep tenants up to date. Challenges and Benefits When airports were asked what the most significant chal- lenge encountered, replies included the following: 1. The toughest challenge was to try to assemble the dif- ferent practices and ways of operating into a single pro- cess or function, 2. The most significant challenge was trying to build and manage the program simultaneously, and 3. Trying to understand TC’s expectations for program development and implementation. These challenges were overcome by a variety of methods, including developing working groups, continuously review- ing the program and documentation, and working closely with TC both regionally and nationally to align the airport’s program and TC’s regulatory requirements. Airports also created a national working group that shared and reported best practices. Some of the benefits noted from the interviewees included the following: 1. Breaking old ways and procedures by introducing new methods through SMS; SMS allowed for staff to report on operational deficiencies or inaccuracies through the program and standard operating procedures were adjusted to reflect the changes. 2. Integration of disparate departments and staff through collective assessment of risk and budgetary management. 3. Data collection and reporting are used for trending and provide a higher level of awareness. 4. Increased awareness throughout the organization with regard to safety and hazard identification. 5. Increased reporting, especially for the nonpunitive reporting program. All three airports reported that they will continue pursuing SMS (required by TC) but airports also commented that they would likely be implementing it even without the require- ment. One airport quoted “SMS is a classic management sys- tem, why are we afraid of it?” Another airport commented that the ability to make decisions on reliable data, not just gut decisions, is a key benefit to the program. Also, the program audits and review offer management a consistent report on safety and ensure that budget and funding are in place. In the past there was no structured way of identifying and develop- ing proactive safety programs. Consistently airports stated that with SMS, communication across departments and with tenants improved, safety awareness increased, and, although the program was challenging to develop and implement, improvements are underway.