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UNIT 11 Air Transport Safety Management Principle 219
Notes
Unit 11 __________________
__________________
Air Transport Safety __________________

Management Principle __________________

__________________
__________________

Objectives __________________
__________________
After reading this unit, you will be able to:
__________________
 Understand Basic Concept of Safety
__________________
 Understand ICAO Requirments
 Understand the need for Safety Management
 Know about various Approaches to Safety Management
 Differentiate between hazard and Incident Reporting

11.1 GENERAL
Aviation is remarkable for the giant technological leaps it
has made over the last century. This progress would not have
been possible without parallel achievements in the control
and reduction of aviation's safety hazards. Given the many
ways that aviation can result in injury or harm, those
involved with aviation have been preoccupied with
preventing accidents since the earliest days of flying.
Through the disciplined application of best safety
management practices, the frequency and severity of aviation
occurrences have declined significantly.

11.2 CONCEPT OF SAFETY

11.2.1 In order to understand safety management, it is
necessary to consider what is meant by "safety".

Depending on one's perspective, the concept of aviation

safety may have different connotations, such as:

a) zero accidents (or serious incidents), a view widely held

by the travelling public;
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Notes b) the freedom from danger or risks, i.e. those factors which
__________________ cause or are likely to cause harm;
__________________
c) the attitude towards unsafe acts and conditions by
__________________
employees (reflecting a "safe" corporate culture);
__________________
__________________ d) the degree to which the inherent risks in aviation are
"acceptable";
__________________
__________________ e) the process of hazard identification and risk
__________________ management; and
__________________
f) the control of accidental loss (of persons and property,
__________________ and damage to the environment).

11.2.2 While the elimination of accidents (and serious

incidents) would be desirable, a one hundred per cent safety
rate is an unachievable goal. Failures and errors will occur,
in spite of the best efforts to avoid them. No human activity
or human-made system can be guaranteed to be absolutely
safe, i.e. free from risk.

Safety is a relative notion whereby inherent risks are

acceptable in a "safe" system.

11.2.3 Safety can be defined as below:

Safety is the state in which the risk of harm to persons or of

property damage is reduced to, and maintained at or below,
an acceptable level through a continuing process of hazard
identification and risk management.

11.3 NEED FOR SAFETY MANAGEMENT

11.3.1 Although major air disasters are rare events, less
catastrophic accidents and a whole range of incidents occur
more frequently. These lesser safety events may be
forerunners of underlying safety problems. Ignoring these
underlying safety hazards could pave the way for an increase
in the number of more serious accidents.

11.3.2 Accidents (and incidents) cost money. Although

purchasing "insurance" can spread the costs of an accident
over time, accidents make bad business sense. While
insurance may cover specified risks, there are many
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UNIT 11 Air Transport Safety Management Principle 221
uninsured costs. In addition, there are less tangible (but no Notes
less important) costs such as the loss of confidence of the __________________
travelling public. An understanding of the total costs of an __________________
accident is fundamental to understanding the economics of __________________
safety. __________________

11.3.3 The air transportation industry's future viability may __________________

well be predicated on its ability to sustain the public's __________________
perceived safety while travelling. The management of safety __________________
is therefore a prerequisite for a sustainable aviation __________________
business. __________________
__________________
11.4 ICAO REQUIREMENTS
11.4.1 Safety has always been the overriding consideration
in all aviation activities. This is reflected in the aims and
objectives of ICAO as stated in Article 44 of the Convention
on International Civil Aviation (Doc 7300), commonly known
as the Chicago Convention, which charges ICAO with
ensuring the safe and orderly growth of international civil
aviation throughout the world.

11.4.2 In establishing States' requirements for the

management of safety, ICAO differentiates between safety
programmes and safety management systems (SMS) as
follows:

 A safety programme is an integrated set of regulations

and activities aimed at improving safety.

 A safety management system (SMS) is an organized

approach to managing safety, including the necessary
organizational structures, accountabilities, policies and
procedures.

11.4.3 ICAO's Standards and Recommended Practices

(SARPs) require that States establish a safety programme
to achieve an acceptable level of safety in aviation operations.
The acceptable level of safety shall be established by the
State(s) concerned. While the concept of safety programmes
and SMS is restricted to Annexes 6, 11 and 14 at present, it
is possible that the concept will be expanded to include
additional operational Annexes in the future.
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Notes 11.4.4 A safety programme will be broad in scope, including

__________________ many safety activities aimed at fulfilling the programme's
__________________ objectives. The safety programme may include provisions for
__________________ such diverse activities as incident reporting, safety
__________________ investigations, safety audits and safety promotion.
__________________ 11.4.5 Therefore, in accordance with the provisions of ICAO
__________________ Annexes 6, 11 and 14, States shall require that individual
__________________ operators, maintenance organizations, ATS providers and
__________________ certified aerodrome operators implement SMS accepted by
__________________
the State. As a minimum, such SMS shall
__________________ a) identify safety hazards;

b) ensure that remedial actions necessary to mitigate the

risks/hazards are implemented; and

c) provide for continuous monitoring and regular

assessment of the safety level achieved.

11.4.6 An organization's SMS accepted by the State shall also

clearly define lines of safety accountability, including a direct
accountability for safety on the part of senior management.

11.4.7 ICAO provides specialized guidance material,

including the manual for Safety Management System (ICAO
DOC 9859), for the fulfilment of the SARPs. This manual
includes a conceptual framework for managing safety and
establishing an SMS as well as some of the systemic processes
and activities used to meet the objectives of a State's safety
programme.

Acceptable level of safety

11.4.8 In any system, it is necessary to set and measure
performance outcomes in order to determine whether the
system is operating in accordance with expectations, and to
identify where action may be required to enhance
performance levels to meet these expectations.

11.4.9 The introduction of the concept of acceptable level of

safety responds to the need to complement the prevailing
approach to the management of safety based upon regulatory
compliance, with a performance-based approach. Acceptable
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UNIT 11 Air Transport Safety Management Principle 223
level of safety expresses the safety goals (or expectations) of Notes
an oversight authority, an operator or a service provider. It __________________
is a reference against which the oversight authority can __________________
measure safety performance. In determining an acceptable __________________
level of safety, it is necessary to consider such factors as the __________________
level of risk that applies, the cost/benefits of improvements
__________________
to the system, and public expectations on the safety of the
__________________
aviation industry.
__________________
11.4.10 In practice, the concept of acceptable level of safety __________________
is expressed by two measures/metrics (safety performance __________________
indicators and safety performance targets) and implemented
__________________
through various safety requirements.

 Safety performance indicators are a measure of the

safety performance of an aviation organization or a sector
of the industry. Safety indicators should be easy to
measure and be linked to the major components of a
State's safety programme, or an operator's/service
provider's SMS.

Safety indicators will therefore differ between

segments of the aviation industry, such as aircraft
operators, aerodrome operators or ATS providers.

 Safety performance targets (sometimes referred to as

goals or objectives) are determined by considering what
safety performance levels are desirable and realistic for
individual operators/ service providers. Safety targets
should be measurable, acceptable to stakeholders, and
consistent with the State's safety programme.

 Safety requirements are needed to achieve the safety

performance indicators and safety performance targets.
They include the operational procedures, technology,
systems and programmes to which measures of
reliability, availability, performance and/or accuracy can
be specified.

11.4.11 The relationship between acceptable level of safety,

safety performance indicators, safety performance targets
and safety requirements is as follows:
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Notes -acceptable level of safety is the overarching concept;

__________________
-safety performance indicators are the measures/metrics used
__________________
to determine if the acceptable level of safety has been
__________________
achieved;
__________________
__________________ -safety performance targets are the quantified objectives
pertinent to the acceptable level of safety; and
__________________
__________________ -safety requirements are the tools or means required to
__________________ achieve the safety targets.
__________________
11.4.12 Safety indicators and safety targets may be different
__________________ (for example, the safety indicator is 0.5 fatal accidents per
100 000 hours for airline operators, and the safety target is a
40 per cent reduction in fatal accident rate for airline
operations), or they may be the same (for example, the safety
indicator is 0.5 fatal accidents per 100 000 hours for airline
operators, and the safety target is not more than 0.5 fatal
accidents per 100 000 hours for airline operators).

11.4.13 Establishing acceptable level(s) of safety for the safety

programme does not replace legal, regulatory, or other
established requirements, nor does it relieve States from
their obligations regarding the Convention on International
Civil Aviation (Doc 7300) and its related provisions. Likewise,
establishing acceptable level(s) of safety for the SMS does
not relieve operators/service providers from their obligations
under relevant national regulations, and those arising from
the Doc 7300.

Examples of implementation
11.4.14 State safety programme.

An oversight authority establishes an acceptable level of

safety to be achieved by its safety programme that will be
expressed by:

a) 0.5 fatal accidents per 100 000 hours for airline operators
(safety indicator) with a 40 per cent reduction in five
years (safety target);

b) 50 aircraft incidents per 100 000 hours flown (safety

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UNIT 11 Air Transport Safety Management Principle 225
indicator) with a 25 per cent reduction in three years Notes
(safety target); __________________
__________________
c) 200 major aircraft defect incidents per 100 000 hours
__________________
flown (safety indicator) with a 25 per cent reduction over
the last three-year average (safety target); __________________
__________________
d) 1.0 bird strike per 1 000 aircraft movements (safety
__________________
indicator) with a 50 per cent reduction in five years
__________________
(safety target);
__________________
e) no more than one runway incursion per 40 000 aircraft __________________
movements (safety indicator) with a 40 per cent __________________
reduction in a 12-month period (safety target); and

f) 40 airspace incidents per 100 000 hours flown (safety

indicator) with a 30 per cent reduction over the five-
year moving average (safety target).

11.4.15 The safety requirements to achieve these safety

targets and safety indicators include:

a) the oversight authority accident prevention programme;

b) a mandatory occurrence reporting system;

c) a voluntary occurrence reporting system;

d) a bird strike programme; and

e) the deployment of radar systems in the State's three

busiest airports within the next 12 months.

11.4.16 Airline operator SMS.

An oversight authority and an airline operator agree on an

acceptable level of safety to be achieved by the operator SMS,
one measure of which - but not the only one - is 0.5 fatal
accidents per 100 000 departures (safety indicator); a 40 per
cent reduction in five years (safety target) and - among others
- the development of GPS approaches for airfields without
ILS approaches (safety requirement).

11.4.17 Service provider and aerodrome operator SMS.

An oversight authority, an ATS provider and an aerodrome

operator agree on an acceptable level of safety to be achieved
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Notes by the provider and operator SMS, one element of which -

__________________ but not the only one - is no more than one runway incursion
__________________ per 40 000 aircraft movements (safety indicator); a 40 per
__________________ cent reduction in a 12-month period (safety target) and -
__________________ among others - the establishment of low visibility taxi
procedures (safety requirement).
__________________
__________________
11.6 APPROACHES TO SAFETY MANAGEMENT
__________________
__________________ 11.5.1 With global aviation activity forecast to continue to
rise, there is concern that traditional methods for reducing
__________________
risks to an acceptable level may not be sufficient. New
__________________
methods for understanding and managing safety are
therefore evolving.

11.5.2 Safety management may therefore be considered from

two different perspectives - traditional and modern.

Traditional perspective
11.5.3 Historically, aviation safety focused on compliance with
increasingly complex regulatory requirements. This
approach worked well up until the late 1970s when the
accident rate levelled off.

Accidents continued to occur in spite of all the rules and

regulations.

11.5.4 This approach to safety reacted to undesirable events

by prescribing measures to prevent recurrence. Rather than
defining best practices or desired standards, such an approach
aimed at ensuring minimum standards were met.

11.5.5 With an overall fatal accident rate in the vicinity of

10-6 (i.e. one fatal accident per one million flights), further
safety improvements were becoming increasingly difficult
to achieve using this approach.

Modern perspective
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UNIT 11 Air Transport Safety Management Principle 227
Notes
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________

Figure- Safety management process

Strategies to reduce or eliminate the hazards are then

developed and implemented with clearly established
accountabilities. The situation is reassessed on a continuing
basis, and additional measures are implemented as required.

11.5.6 The steps of the safety management process outlined

in Figure above are briefly described below:

a) Collect the data.

b) Analyse the data.

c) Prioritize the unsafe conditions.

d) Develop strategies. It may include;

1) Spread the risk across as large a base of risk-

takers as practicable. (This is the basis of
insurance.)

2) Eliminate the risk entirely (possibly by ceasing

that operation or practice).

3) Accept the risk and continue operations

unchanged.

4) Mitigate the risk by implementing measures to

reduce the risk or at least facilitate coping with
the risk.
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Notes When selecting a risk management strategy, care is required

__________________ to avoid introducing new risks that result in an unacceptable
__________________ level of safety.
__________________
e) Approve strategies.
__________________
__________________ f) Assign responsibilities and implement strategies.
__________________ g) Re-evaluate situation.
__________________
h) Collect additional data.
__________________
__________________ 11.5.7 Safety management requires analytical skills that may
__________________ not be routinely practiced by management. The more complex
the analysis, the more important is the need for the
application of the most appropriate analytical tools. The
closed loop process of safety management also requires
feedback to ensure that management can test the validity of
its decisions and assess the effectiveness of their
implementation.

Safety oversight
11.5.8 The term safety oversight refers to the activities of a
State under its safety programme, while safety performance
monitoring refers to the activities of an operator or service
provider under its SMS.

11.5.9 Safety oversight or safety performance monitoring

activities are an essential component of an organization's
safety management strategy. Safety oversight provides the
means by which a State can verify how well the aviation
industry is fulfilling its safety objectives.

11.5.10 Some of the requirements for a safety performance

monitoring system will already be in place in many
organizations. For example, States would normally have
regulations relating to mandatory reporting of accidents and
incidents.

11.5.11 In order to keep safety risks at an acceptable level

with the increasing levels of activity, modern safety
management practices are shifting from a purely reactive to
a more proactive mode.
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UNIT 11 Air Transport Safety Management Principle 229
11.5.12 No single element will meet today's expectations for Notes
risk management. Rather, an integrated application of most __________________
of these elements will increase the aviation system's __________________
resistance to unsafe acts and conditions. However, even with __________________
effective safety management processes, there are no __________________
guarantees that all accidents can be prevented.
__________________
11.5.13 Even where the risk is classed as acceptable __________________
(tolerable), if any measures that could result in the further __________________
reduction of the risk are identified, and these measures __________________
require little effort or resources to implement, then they __________________
should be implemented.
__________________
11.5.14 The acronym ALARP is used to describe a risk that
has been reduced to a level that is as low as reasonably
practicable. In determining what is "reasonably practicable"
in this context, consideration should be given to both the
technical feasibility of further reducing the risk, and the cost;
this could include a cost-benefit study.

11.5.15 Showing that the risk in a system is ALARP means

that any further risk reduction is either impracticable or
grossly outweighed by the costs. It should, however, be borne
in mind that when an individual or society "accepts" a risk,
this does not mean that the risk is eliminated. Some level of
risk remains; however, the individual or society has accepted
that the residual risk is sufficiently low that it is outweighed
by the benefits.

11.5.16 These concepts are illustrated diagrammatically in

the Tolerability of Risk (TOR) triangle in Figure below. (In
this figure, the degree of risk is represented by the width of
the triangle.)
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Notes
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________
__________________

Tolerability of Risk (TOR) triangle

11.6 ACCIDENTS VERSUS INCIDENTS

11.6.1

a) An accident is an occurrence during the operation of an

aircraft which entails:

1) a fatality or serious injury;

2) substantial damage to the aircraft involving

structural failure or requiring major repair; or

3) the aircraft is missing or is completely inaccessible.

b) An incident is an occurrence, other than an accident,

associated with the operation of an aircraft which affects
or could affect the safety of operation. A serious incident
is an incident involving circumstances indicating that
an accident nearly occurred.

1: 600 Rule

11.6.2 Research into industrial safety in 1969 indicated that

for every 600 reported occurrences with no injury or damage,
there were some:
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UNIT 11 Air Transport Safety Management Principle 231
 30 incidents involving property damage; Notes
__________________
 10 accidents involving serious injuries; and
__________________
 1 major or fatal injury. __________________
__________________
11.6.3 The 1-10-30-600 ratio shown in Figure below is
indicative of a wasted opportunity if investigative efforts are __________________

focused only on those rare occurrences where there is serious __________________

injury or significant damage. __________________
__________________
__________________
__________________

Figure-----1: 600 Rule

The factors contributing to such accidents may be present in

hundreds of incidents and could be identified -before serious
injury or damage ensues. Effective safety management
requires that staff and management identify and analyse
hazards before they result in accidents.

AIRCRAFT OPERATIONS

11.7 GENERAL
11.7.1 ICAO requires States to establish a safety programme
in order to achieve an acceptable level of safety in the
operation of aircraft. As part of their safety programme,
States require operators to implement an accepted safety
management system (SMS).

11.7.2 An SMS allows operators to integrate their diverse

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Notes safety activities into a coherent system.

__________________
Examples of safety activities that might be integrated into
__________________
an operator's SMS include:
__________________
__________________ a) hazard and incident reporting;
__________________ b) Flight Data Analysis (FDA);
__________________
c) Line Operations Safety Audit (LOSA); and
__________________
__________________ d) cabin safety.
__________________
__________________
11.8 HAZARD AND INCIDENT REPORTING
11.8.1 The principles and operation of successful incident
reporting systems have been established. Nowadays, many
operators have made this commitment to safety and, as a
result, benefited not only from improved hazard
identification but also from improved efficiencies in flight
operations.

Benefits
11.8.2 Incident reporting systems are one of an operator's
most effective tools for proactive hazard identification, a key
element of effective safety management. Policies, procedures
and practices developed within an organization sometimes
introduce unforeseen hazards into aircraft operations. These
latent conditions (hazards) may lie dormant for years. They
are usually introduced unknowingly, often with the best of
intentions. Examples include poor equipment design,
inappropriate management decisions, ambiguously written
procedures and inadequate communication between
management and line personnel. Line management can also
introduce such hazards by instituting operating procedures
that do not work as intended under "real world" conditions.
In short, hazards may have their origins far removed in space
and time from the incidents that may eventually result from
them.

11.8.3 An accident or incident may not result from these

hazards immediately because "front-line personnel" (whether
they be pilots, ATCOs or AMEs) often develop ways of coping
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UNIT 11 Air Transport Safety Management Principle 233
with the hazard - sometimes described as "work arounds". Notes
However, if the hazards are not identified and addressed, __________________
sooner or later the coping mechanisms fail and an accident __________________
or incident ensues. __________________

11.8.4 A properly managed in-house reporting system can __________________

help companies identify many of these hazards. By collecting, __________________

aggregating and then analysing hazard and incident reports, __________________
safety managers can better understand problems __________________
encountered during operations. Armed with this knowledge, __________________
they can initiate systemic solutions, rather than short-term __________________
fixes that may only hide the real problems.
__________________

Encouraging the free flow of safety information

11.8.5 The trust of employees in the incident reporting
system is fundamental to the quality, accuracy and substance
of data reported. If hazard and incident data are collected in
a corporate atmosphere where employees feel free to openly
share safety information, the data will contain much useful
detail. Since it will represent the actual environment, it will
be helpful in determining contributing factors and areas of
safety concern.

11.8.6 On the other hand, if the company uses incident reports

for disciplinary purposes, the company incident reporting
system will only receive the minimum information required
to comply with company rules. Little useful information from
a safety perspective could be expected.

11.8.7 The trust necessary for the free flow of safety

information is very fragile. It may take years to establish;
yet, one breach of that trust may undermine the effectiveness
of the system for a long time.

To be effective, as a minimum, an operator's reporting

programme should include hazard and incident reports from
flight operations personnel, AMEs and cabin crew.

Commercially available systems

11.8.9 An increasing number of commercially available
incident reporting systems that run on personal computers
(PCs) and are available at relatively low cost, have proven
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Notes to be well suited for company reporting systems. These off-

__________________ the-shelf software packages collect and store data, generate
__________________ reports, and can be used for trend analysis and safety
__________________ performance monitoring.
__________________ 11.8.10 Three examples of such systems are listed below:
__________________
a) British Airways Safety Information System (BASIS)
__________________
website at http://www.winbasis.com.
__________________
__________________ b) INDICATE (Identifying Needed Defences in the Civil
__________________ Aviation Transport Environment), developed in
__________________
Australia, website at http://www.atsb.gov.au.

c) Aircrew Incident Reporting System (AIRS) was

developed by Airbus Industrie

11.9 FLIGHT DATA ANALYSIS (FDA) PROGRAMME

11.9.1 Flight Data Analysis (FDA) programmes, sometimes
referred to as Flight Data Monitoring (FDM), or Flight
Operations Quality Assurance (FOQA), provide another tool
for the proactive identification of hazards. FDA is a logical
complement to hazard and incident reporting and to LOSA.

11.10 LINE OPERATIONS SAFETY AUDIT (LOSA)

PROGRAMME
11.10.1 As has been discussed earlier, the negative
consequences of human behaviour can be proactively
managed. Hazards can be identified, analysed and validated
based on data collected through the monitoring of day-to-
day operations. Line Operations Safety Audits (LOSA) are
one method for monitoring normal flight operations for safety
purposes. LOSA programmes then provide another proactive
safety management tool.

ICAO endorses LOSA as a way to monitor normal flight

operations.

11.11 CABIN SAFETY PROGRAMME

General
11.11.1 Cabin safety is aimed at minimizing risks to the
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UNIT 11 Air Transport Safety Management Principle 235
occupants of the aircraft. By reducing or eliminating hazards Notes
with the potential for creating injuries or causing damage, __________________
cabin safety focuses on providing a safer environment for __________________
the occupants of the aircraft. __________________

11.11.2 The range of threats to the aircraft and its occupants __________________

include: __________________
__________________
a) in-flight turbulence;
__________________
b) smoke or fire in the cabin; __________________
__________________
c) decompression;
__________________
d) emergency landings;

e) emergency evacuations; and

f) unruly passengers.

11.11.3 The work environment and working conditions for

cabin crew are influenced by a diverse set of human
performance issues that may affect how cabin crew respond
to threats, errors and other undesirable situations.

11.11.4 The cabin crew are usually the only company

representatives that passengers see while in the aircraft.
From the passengers' perspective, the cabin crew are there
to provide in-flight service. From a regulatory and
operational perspective, cabin crew are on board to manage
adverse situations that may develop in the aircraft cabin and
to provide direction and assistance to passengers during an
emergency.

ICAO requirements
11.11.5 Although ICAO does not require cabin crew to be
licensed, Chapter 12 of Annex 6 - Operation of Aircraft
specifies requirements with respect to:

a) assignment of emergency duties;

b) role during emergency evacuations;

c) use of emergency equipment;

d) flight- and duty-time limits; and

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Notes e) training.
__________________
__________________ Cabin safety standards
__________________ 11.11.6 Safety inspections, safety surveys and safety audits
__________________ are tools that can be used to ensure that requisite cabin safety
__________________ standards are being maintained. Once an operator is
__________________ certificated, cabin safety standards may be confirmed through
__________________
an ongoing programme of:
__________________ a) aircraft inspections (e.g. emergency exits, emergency
__________________ equipment, and galleys);
__________________
b) pre-flight (ramp) inspections;

c) in-flight cabin inspections (e.g. passenger briefings and

demonstrations, crew briefings and use of checklists,
crew communications, discipline, and situational
awareness);

d) training inspections (e.g. facilities, quality of instruction,

and records); and

e) base inspections (e.g. crew scheduling, dispatch, safety

incident reporting and response), etc.

11.11.7 A company's internal safety audit programme should

include the cabin crew department. The audit process should
include a review of all cabin operations, as well as an audit
of cabin safety procedures, training, the cabin crew's
operating manual, etc.

11.12 DGCA's Programme for Safety Regulation

And Oversight Of Flight Operations for
Indian Operators.
DGCA vide their Civil Aviation Requirements (CAR) Section
8, - Aircraft Operations Series 'A' Part II Issue I, Dated 16th
October, 1995, issued their Programme for Safety Regulation
And Oversight Of Flight Operations for Indian Operators,
with motto of the Strict adherence to the laid down operating
procedures and limitations and compliance with the rules
and regulations.
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UNIT 11 Air Transport Safety Management Principle 237
The main objective of the programme was to ensure: Notes
__________________
a) effective implementation of the safety related Standards
__________________
and Recommended Practices contained in the ICAO
__________________
Annexes, particularly Annexes 1 and 6 and the relevant
rules, regulations, procedures and requirements laid __________________
down in the various national regulatory documents; __________________
__________________
b) that safety weaknesses in the flight operations are
__________________
identified and necessary corrective measures are taken
in time before they become a potential safety hazard; __________________
and __________________
__________________
c) that the capability of the operator to conduct the
operations safely be maintained at or above the level
required by the regulations.

11.12.1 The Civil Aviation Requirement (CAR) identified the

important operational aspects which needed close
monitoring and described broadly the system of safety
oversight required to be exercised on the air transport
operations by the operators and the DGCA officers.

Compliance of the requirements of the CAR was made

applicable to all Indian operators engaged in scheduled air
transport services for carriage of passengers, mail or cargo
and to Non-Scheduled/Air Taxi Operators. For new operators
seeking permission to commence operations, it was to be a
pre-requisite for the grant of the operating permit.

The main points of the CAR are given below;

11.13 SAFETY REGULATION OF FLIGHT OPERA-

TIONS
Various statutory/regulator documents, namely, the Aircraft
ACT 1934, the Aircraft Rules 1937, Aeronautical Information
Publication (AIP) India, Aeronautical Information Circulars
(AIC), Civil Aviation Requirements (CAR) etc. stipulate the
safety and operational requirements applicable to different
types of operations, which shall be complied with by the
operators. In addition, implementation of the following
important safety and operational requirements shall be
closely monitored by the operators and DGCA Officers to
enhance safety of operations.
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Notes 11.13.1 In accordance with Rule 134 of the Aircraft Rules,

__________________ 1937, no person shall operate any air transport service in
__________________ India without obtaining the necessary permit for operating
__________________ such services. The operating permit shall be maintained
__________________ current and valid and the operations shall be conducted
within the scope and provisions of the permit.
__________________
__________________ 11.13.2 The operators shall demonstrate, before grant of the
__________________ permit, their capability to safely operate the air transport
__________________ services sought to be operated. It shall be ensured that the
__________________
manpower, infrastructure, facilities, systems and operating
capability does not degrade below the required level at any
__________________
time and is enhanced continually commensurate with
expansion of operations.

11.13.3 The operators shall clearly outline in their operations

manual their policy relating to flight operations in accordance
with the provisions of ICAO Annex 6, Aircraft Rules, 1937
and the applicable CARs and shall also lay down the
procedures for implementation of the same.

11.13.4 The Chief of Operations shall be overall responsible

for implementation of the flight operations policy. For this
purpose, the operators shall have flight operations offices at
the main base and also at the regional stations exercising
control on the flight operations. The operations offices shall
bemoaned by adequate number of operations officers, flight
dispatchers approved by DGCA and other supporting staff.
The strength of such officers shall have to be increased as
the size of operating fleet grows.

11.13.5 The operations manual, CARs, AIP - India, Aircraft

Rules, AICs, flight manual, Jeppeson manual, relevant ICAO
Annexes and related guidance material, check-lists and other
operations documents shall be kept up-to-date by the
operations offices. The operator shall remain on the mailing
list of the suppliers of these documents for the purpose of
receiving regular amendments, wherever such a service is
available.

11.13.6 A master folder for each type of regulatory/policy

document viz. CARs, AICs, Operations Circulars, and Safety
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UNIT 11 Air Transport Safety Management Principle 239
Bulletins etc. shall be maintained by the operations offices Notes
for reference by crew members and other personnel. __________________
__________________
11.13.7 Whenever any new aircraft operations requirement
__________________
or circular is issued by the aircraft manufacturer, DGCA or
the operator, the operations offices shall bring the same to __________________

the notice of all their concerned personnel and ensure __________________

compliance. The operations manual shall also be amended __________________
from time to time, as required. __________________
__________________
11.13.8 There shall be a proper system of distribution of the
circulars and other documents to all crew members and other __________________

concerned personnel. __________________

11.13.9 Whenever a new crew or an operations officer is

appointed, the operator shall give him/her a thorough
familiarization of the operations manual, the standing
operations circulars and other relevant documents.

11.13.10 The operations offices shall have a proper system

of maintaining operational and flight records of personnel
and shall monitor records of each crew member (including
foreign crew, if employed) in order to ensure that:

a) the flight and duty time limitations are complied with;

b) their licences, instrument ratings etc. are maintained

valid;

c) Validity of their medical checks.

d) all proficiency checks are carried out as per the

procedures and within the stipulated periods; and

e) periodic refreshers are undergone as required.

For this purpose, a fool-proof system of record keeping in

proper formats, preferably a computer based system, shall
be established and followed.

11.13.11 All the flight crew members shall undergo periodic

refresher and flight safety courses as stipulated. During the
crew training and refresher courses, all the new operations
and safety circulars and bulletins, major accident/incident
case studies shall be discussed.
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Notes 11.13.12 The operators shall specify procedures for ensuring

__________________ flight crew proficiency for:
__________________
i) Commencement of operations after long leave/
__________________
grounding i.e. more than 30 days;
__________________
__________________ ii) Corrective training and checks after failure in a
proficiency check.
__________________
__________________ 11.13.13 The operators shall establish specific operating
__________________ procedures/precautions for:
__________________
i) Operations to critical airports of their operating network
__________________ i.e. airports surrounded by hilly/difficult terrain,
satellite airfields etc;

ii) Operations to airfields having marginal runway length;

iii) Operations during monsoon period; and

iv) Operations during winter to airfields which become fog

bound.

11.13.14 The operators shall lay down and obtain DGCA

approval of their airport weather minimums and ensure
adherence to the same by their flight crewmembers.

11.13.15 Suitable alternate aerodrome for each airport on

their network shall be designated by the operators, which
shall meet the minimum safety requirements for safe
operation of the aircraft type, keeping also in view the watch
hours of the airport.

11.13.16 Minimum reserve fuel as laid down in AIP India

shall always be carried on each flight.

11.13.17 The operators shall have facilities and doctors for

carrying out pre-flight medical checks of their crew members
as per the requirements. The equipment used for the purpose
must be reliable to give accurate digital record of
observations. It shall be calibrated frequently, at least once
in a year or as per the manufacturer's requirements.

11.13.18 The operators shall have, trained/qualified and

DGCA approved load and trim sheet personnel at each airport
for the type of aircraft operated. The operator shall ensure
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UNIT 11 Air Transport Safety Management Principle 241
that in no case the aircraft is loaded beyond the maximum Notes
permissible limits determined from runway length (takeoff/ __________________
landing) requirement, climb and enroute obstacle clearance __________________
or any other limitation. It would be desirable that the __________________
operators should have appropriate charts for each airport __________________
giving the RTOLW (Rejected Take off and Landing Weight)
__________________
at different ambient temperatures and wind conditions.
__________________
11.13.19 Only trained, qualified and DGCA approved cabin __________________
crew shall be employed and they shall undergo periodical __________________
refresher and flight safety courses. __________________

11.13.20 The operators shall train adequate number of __________________

experienced pilots and obtain approval from DGCA for them
to act as Check Pilots, Instructors and Examiners on the type
of aircraft operated to carry out the training and proficiency
checks of pilots and also for monitoring the flight operations.
In case an operator does not have its own experienced pilots
suitable for training as Check Pilot/Instructor/Examiner, the
operator may use pilots of the other operators or foreign
pilots approved by the DGCA to discharge these functions
on the type of aircraft.

11.13.21 The operators engaged in carriage of cargo only and

those authorized to carry dangerous goods, shall train
adequate number of personnel in handling dangerous goods
and shall ensure that all stipulated requirements with regard
to packaging, handling, loading/unloading and transportation
of such goods are complied with.

11.13.22 The operators engaged in over-water operations

with twin engined aircraft shall ensure compliance of the
requirements relating to ETOP operations (Extended Range
Twin- Engine Operations).

11.13.23 The operators shall carry out regular in flight

monitoring of their flight operations to ensure compliance
with the operating procedures through the senior
commanders and the internal safety audit team. Records of
the deficiencies observed and the corrective actions taken
shall be maintained.

11.13.24 In addition to other information, extensive use of

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Notes the data recorded on the flight recorders (CVR/ FDR) should
__________________ be made by the Chief of Operations in the performance
__________________ monitoring the flight crew, thus permitting early detection
__________________ of safety hazards and the initiation of appropriate accident
__________________ prevention measures.
__________________ Corrective measures shall be taken immediately when any
__________________ deficiency is observed.
__________________
11.13.25 Based on the experience of flight operations, the
__________________
operators shall issue operations circulars to eliminate any
__________________ weak or potentially dangerous area in their operations.
__________________
11.13.26 The operators shall prepare operational flight plan
for each route including diversion sectors giving information
on route navigation, fuel requirements, flight time/speed/
distance between different reporting points, maximum
permissible weights, airport weather minimas and other
safety related information.

11.13.27 Before commencing operations to a new station, the

operator shall carry out assessment of the suitability of the
airport for safe operations of the type of aircraft intended to
be operated particularly from the point of view of runway
length and strength, one engine inoperative approach, take
off and climb procedures and capability, adequacy of fire
fighting and rescue facilities, clearance of enroute obstacles
in case of an engine failure and the other safety related
conditions.

Requirements of CAR Section 3, Series 'E', Part I, dated 1st

March 1994 ("Minimum Requirements for Grant of Permit
to Operate Scheduled Passenger Air Transport Services.")
shall be complied with before commencing operations to new
stations.

11.13.28 In cases where the aircraft used by an operator have

been procured on wet lease the operations office shall ensure
compliance with the applicable operations requirements for
operations with wet-leased aircraft.

11.13.29 If a foreign pilot is employed by an Operator, the

operator shall ensure that the pilot has at least 500 hours
experience as PIC on the type (with licence, ratings and
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UNIT 11 Air Transport Safety Management Principle 243
medical current) and has adequate working knowledge of Notes
the English language, DGCA may grant exemption from this __________________
requirement in specific cases where the operator satisfies __________________
the Director General that safety will not be compromised. __________________

11.13.30 An operator employing any foreign pilot shall obtain __________________

for him the required security clearance through DGCA __________________

before that pilot is scheduled for operations. That pilot shall __________________
also be given thorough familiarization about Indian Rules __________________
and Regulations, operating procedures, facilities available __________________
at different airports, prohibited areas, current Notams and __________________
the operations manual of the operator. After the Chief of
__________________
Operations is satisfied with and has certified the aforesaid
briefing, the pilot shall be required to pass an oral check by
a DGCA board and then only his licence shall be revalidated
to fly Indian registered aircraft.

11.13.31 For scheduling a foreign pilot for operations unto a

period of three months, the operator, in addition to fulfilling
the requirements of Para 11.13.30, shall ensure that an Indian
pilot forms part of the crew complement.

11.13.32 A foreign pilot shall be permitted to operate Indian

registered aircraft regularly as a line pilot for more than
three months only if has passed the DGCA's written
examination in Air Regulations.

11.13.33 Whenever any crew member of an operator joins

another operator, that crewmember shall be familiarized
with the operations manual of the new operator which shall
be followed by the oral check by a DGCA board before that
crewmember is scheduled for operations.

11.13.34 The operators shall have a system of frequent

exchange of information between pilots and engineers to
improve coordination and understanding of operational and
airworthiness aspects. A record of such discussions shall be
maintained.

11.13.35 Any differences between various aircraft of the same

type in the fleet of an operator, shall be circulated to all the
flight crew members. Adequate briefing should be given to
them as required.
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Notes 11.13.36 The operators shall emphasize to all their pilots that
__________________ they should meticulously record the snags in the aircraft as
__________________ and when observed.
__________________
11.13.37 While accepting an aircraft, the pilots shall ensure
__________________ that snags carried forward, if any, are not beyond the scope
__________________ of MEL and the aircraft is loaded within the permissible
__________________ limits of weight and seats. The engineering and commercial
__________________ personnel shall also ensure compliance of these aspects
__________________ respectively.
__________________ 11.13.38 The operators shall prepare a Flight Safety Manual
__________________ giving amongst other information, policies and procedures
relating to investigation of incidents/accidents,
implementation of safety recommendations, safety awareness
and accident/incident prevention programmes. The Chief of
flight Safety of the operators shall be responsible for
implementation of the policies laid down in their Flight
Safety Manuals and all safety measures relating to their flight
operations.

11.13.39 The Chief of Flight Safety shall ensure compliance

with the safety recommendations made in the investigation
reports, safety audit reports, spot checks etc. Proper record
of such implementation shall be maintained.

11.13.40 The Chief of Flight Safety shall arrange periodic

safety audits and make reports on the same. The deficiencies
observed shall be brought to the notice of the concerned
departments and appropriate corrective measures shall be
taken promptly.

11.13.41 The operators shall take all necessary measures to

implement the ICAO programme for prevention of Controlled
Flight into Terrain (CFIT) accidents including the related
ICAO provisions. The operators shall discuss the important
operational aspects of the CFIT programme during initial
and recurrent training of flight crew.

11.13.42 The operators shall make every effort to enhance

accident/incident prevention measures, particularly in the
areas of information feed-back and analysis, voluntary
reporting system and prompt investigation of incidents and
implementation of safety recommendations.
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UNIT 11 Air Transport Safety Management Principle 245
11.13.43 The operators shall take into account relevant Notes
human factors aspects when developing operating __________________
procedures and training of personnel. The operators are __________________
encouraged to engage in cooperation and mutual exchange __________________
of information on problems related to influence of human __________________
factors on the safety of aircraft operations.
__________________
11.13.44 The operators shall lay down in their Training __________________
Manuals, the policies relating to the initial and recurrent __________________
training of their flight crew and operations personnel. __________________

11.13.45 The Chief of Training shall prepare necessary __________________

training programmes for their flight crew and other __________________

operations personnel keeping in view the background of the
persons recruited and the operating requirements. Approval
of the training programmes shall be obtained from DGCA
before commencing the training.

The Chief of Training shall also be responsible for training

of Check Pilots/Instructors/Examiners as per the DGCA
requirements.

11.13.46 Before sending trainees for training to any institute,

the Chief of Training shall ensure that the institute has the
requisite facilities and qualified and approved Instructors
and Examiners and the institute is approved by the
Aeronautical Authority of the Country and also by the DGCA
India for imparting such training.

The training records shall be maintained and submitted to

DGCA as per the standing requirements.

11.13.47 The Chief of Training shall ensure that necessary

changes in the training programmes are carried out, where
necessary, based on the experience and the observations
made during implementation of the safety oversight
programme and safety audits.

11.13.48 In case of any violation, the operator shall promptly

take effective corrective action including punitive action as
necessary to prevent similar occurrences in future. A record
of such action shall be maintained.

11.13.49 To confirm continued capability to conduct the

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Notes operations authorized under the Operating Permit, the

__________________ operators shall submit to the DGCA, while applying for
__________________ renewal of the Operating Permit, the following information:
__________________
a) Continued compliance of the requirements contained in
__________________ CAR Section 3, Air Transport, Series 'C' Part II for grant
__________________ of permission and to operate scheduled air transport
__________________ services.
__________________
b) Report of the in-house safety audit team of the operator
__________________
on the safety audit carried out within 60 days prior to
__________________ expiry of the Operating Permit and the action taken
__________________ thereon.

11.13.50 The Operating Permit of any operator, shall be liable

to revocation if the operator subsequently fails or is unable
to meet the applicable laid down requirements during the
course of its operations under the Permit.

11.14. IMPLEMENTATION OF SAFETY OVERSIGHT

PROGRAMME OF FLIGHT OPERATIONS.
Effective safety regulation and oversight of flight operations
can be achieved only by joint efforts on the part of the
operators and the regulatory authority. It is, therefore,
essential that in addition to the safety oversight programme
of DGCA, the operators should also have their in-house
monitoring programme commensurate with the type and
scale of their operations. Broadly, the safety oversight of
flight operations shall be conducted on the following lines:

11.14.1 The operators shall lay down their policies and

procedures for compliance of the operational, safety and
training requirements in their operations manual, flight
safety manual and training manual. The responsibility of
implementation of the policies and procedures contained in
these manuals may be assigned to their officials as indicated
below:-a) Operations Manual - Chief of Flight Operations b)
Flight Safety Manual - Chief of Flight Safety c) Training
Manual - Chief of Training The division of responsibility for
this purpose shall be clearly reflected in the relevant
manuals.
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UNIT 11 Air Transport Safety Management Principle 247
11.14.2 The day-to-day safety regulation and in-house Notes
monitoring of the flight operations should be exercised by __________________
the Chief of Operations through the senior Pilots, Check __________________
Pilots, Instructors, Examiners and operations officers. __________________
Necessary check lists should be devised for carrying out such __________________
monitoring. There shall be a proper system of documentation
__________________
and recordkeeping of the deficiencies observed and the
__________________
corrective measures taken.
__________________
11.14.3 In addition to the day-to-day monitoring, periodic __________________
in-house safety audits shall be carried out by the dedicated __________________
safety audit teams of the operators to ensure that the safety
__________________
regulations are being complied with. Corrective action shall
be taken immediately by the Chief of Flight Safety on the
deficiencies observed during the audit. Relevant records and
data in proper formats shall be maintained in this regard.

11.14.4 In order to discharge the responsibility for safety

oversight in accordance with the provisions of ICAO Annex.6,
surveillance of flight operations including training shall be
carried out by the DGCA officers viz. Flight Inspectors, safety
audit teams and other authorised officers.

The Operations Manual for Flight Inspectors stipulates the

method of surveillance of airline flight operations. The flight
inspectors shall frequently fly with the airline pilots to carry
out the surveillance in accordance with their Operations
Manual. Deficiencies observed shall be intimated to the
operators for corrective action. Deputy Director Flight Crew
Standards in DGCA Headquarters shall ensure that
necessary actions are taken on the observations made by the
Flight Inspectors.

11.14.5 The DGCA safety audit teams or other authorized

persons shall carry out safety audits of the operators
periodically. The deficiencies observed during these audits
shall be brought to the notice of the concerned operator for
taking necessary corrective measures. The Director of Air
Safety in the DGCA Headquarters shall take appropriate
measures to ensure that necessary actions are taken by the
operators to remove the deficiencies and to implement the
safety recommendations. Where punitive action is required
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Notes to be taken for serious lapses, the Director of Air Safety shall
__________________ initiate the same promptly.
__________________
__________________ 11.15. INDUSTRY CONSULTATION AND REVIEW
__________________ OF IMPLEMENTATION OFTHE SAFETY
__________________ REGULATION AND OVERSIGHT
__________________ PROGRAMME.
__________________ Review of implementation of the safety regulations and
__________________ oversight programme shall be carried out as and when
__________________ required by the DGCA Headquarters jointly with the
__________________ operators to assess functioning and effectiveness of the
programmes. The Deputy Director, Flight Crew Standards
shall coordinate this review. This would also provide an
opportunity to the operators to learn from the experience of
others and to improve their own systems. During the review,
it would also be assessed whether the national rules,
regulations, procedures and requirements are adequate and
effective in the implementation of the relevant ICAO
Standards and Recommended Practices and if found
necessary, appropriate amendments would be suggested.

References:
 ICAO Doc 9859-AN/460-Safety Management Manual
(SMM)

 CAA, UK CAP 712, Safety Management Systems for

Commercial Air Transport Operations-A Guide to
Implementation prepared by the Air Transport
Operations - Safety Management Group

 DGCA Civil Aviation Requirements, Section 8 - Aircraft

Operations, Series 'A' Part Ii, Issue I, Dated 16th
October, 1995 Covering Subject:-Safety Regulation And
Oversight Of Flight Operations.

 Federal Aviation Administration (FAA) Website:

www.faa.gov/avr/afs/atos on Air Transport Oversight
System.

 ICAO Document DOC 9859-AN/460 (Safety Management

Manual).
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UNIT 11 Air Transport Safety Management Principle 249
 Various DGCA Circulars and notifications on "Safety Notes
Management System". __________________
__________________
Questions __________________
__________________
General Questions.
__________________
1. What is the difference between the Safety Performance __________________
Indictors and Safety Targets? Give examples.
__________________
2. What is meant by Safety Management System (SMS)? __________________
What are its advantages and describe various steps __________________
involved in implementation of SMS? __________________

3. In establishing States' requirements for the management

of safety, how ICAO differentiates between safety
programmes and safety management systems (SMS).

4. How Aircraft Accidents and incidents are related to each

other state in the context of 1:600 Rule.

Objective Type of questions

a. Universal Safety Oversight Audit Program (USOAP) is
the program for ….

b. The main features of SMS are Systematic, --- and Explicit.

Answers to Objective Type of questions

a. auditing the implementation of safety related standards
of an organization.

b. Proactive