MINISTRY OF TRANSPORTATION

DIRECTORATE GENERAL OF CIVIL AVIATION

Office Complex Soekarno-Hatta International Airport, C3 St., Tangerang, Banten- Indonesia
Telp.: (+6221) 225 66288, (+6221) 256 08887 Fax. : (+6221) 225 66399
Website : hubud.dephub.go.id; e-mail: daao_dgca@dephub.go.id

EVALUATION OF SMS INTERNAL AUDIT

Company Name Date of Inspection:
Certificate Number
Reference : - CASR 19 - SI 19-05

NO SUBJECT SAT UNSAT N/A

1. IsAthere a procedure for periodic internal audit/assessment of the SMS?

2. Is the procedure available for auditing all relevant areas such as :

a. SMS Manual and procedure
b. Safety policy and objectives;
c. Safety risk management;
d. Safety assurance; and
e. Safety promotion.
3. Does the internal audit program include sub-bases and station?

4. Is there a current internal SMS audit/assessment plan?

5. Does
D the SMS audit plan include the sampling of completed/existing safety
risk assessments?
6. Does the SMS audit plan include the sampling of safety performance
indicators for data currency and their target/alert settings performance?
7. Is there a process for SMS audit/assessment reports to be submitted or
highlighted for the accountable manager’s attention where appropriate.
8. Does the safety internal audit program of surveillance provide a check of
the system's own effectiveness of SMS?
9. Is there a documented internal SMS audit/assessment procedure.

10. Has the SMS audit/assessment been carried out according to plan.

11. Does the SMS audit plan include the sampling of completed safety
assessments.
12. Does the SMS audit plan cover the SMS interface with contractors /sub-
contractors or customers where applicable?
13. is there a follow-up procedure to address audit corrective actions.

14. Does the operator maintain records to provide a historical reference as well
as the current status of all SMS processes such as: a hazard register; an
index of completed safety assessments; SMS/safety training records;
current SPIs and associated safety objectives; internal SMS audit reports;
SMS/safety committee meeting minutes and the SMS implementation plan;

REMARK

DGCA Form No. 120-97 (Mar 2018) Page 1 of 2

 DGCA INSPECTOR

DGCA Form No. 120-97 (Mar 2018) Page 2 of 2