SMS Gap Analysis Tool Air Carrier 7-31-14

NPRM GAP Analysis
SMSVoluntary Program (SMSVP) - Air Carrier Gap Analysis Tool
07/31/14
Note: This SMS Voluntary Program Gap Analysis Tool is not regulatory, but is provided to aid aviation service providers in the evaluation of their existing systems,
processes and programs as compared to SMS requirements in the SMSVoluntary Program Standard. This Gap Analysis Tool can be used by Part 121 Service
Providers as a transition tool for service providers to use until 14 CFR part 5 is published. For Part 121 service providers, when 14 CFR Part 5 rule is published,
if there are discrepancies between this tool and 14 CFR part 5, part 5 shall prevail for affected aircarriers.
Blue colored column headings (C thru I) may be modified, added or deleted to reflect a service providers organizational structure.
Any changes to the questions or references in column A, will render the document inaccurate, resulting in the development of an inacurate Implementation Plan.
Service Provider:
Questions
Component - Safety Policy
Process Objectives
This section provides guidance about how the
accountable executive, in coordination with other
senior managers, define safety performance
objectives, assign accountability, and allocate
resources. The Safety Policy component is where
your management defines their commitment to
managing safety throughout the organization.
SMSVP Requirement
Does your safety management system have a
safety policy component that is in accordance
with SMSVP Standard, subpart B, Safety Policy?
(Note(s): This question addresses the SMS
Safety Policy Component in its entirety and is
best answered after responding to all other
questions within this component.)
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SMSVP Standard: 5.3 (a) (1)
Is your safety management system appropriate to
the size, scope and complexity of your
operations?
SMSVP Standard: 5.3 (a)
Element - Safety Policy

Process Objectives
To provide the organizations decision makers a
means to document, communicate, establish, and
achieve safety objectives for their organization.
The accountable executive will commit to
providing adequate resources to implement the
SMS, achieve safety objectives, a safety reporting
program, an emergency response plan, and
definitions of unacceptable conduct by signing
and regularly reviewing the organizations safety
policy.
SMSVP Requirement
safety policy that includes at least the following
minimum requirements:
Your organization's safety objectives,
A commitment to fulfill your organization's safety
objectives;
A clear statement to commit the necessary
resources for implementating your safety
management system;
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A safety reporting policy that defines
requirements for your employee's to report safety
hazards or issues;
A policy that defines unacceptable behavior and
conditions for disciplinary action; and
An emergency response plan that provides for
the safe transition from normal to emergency
operations in accordance with the requirements
of SMSVP Standard 5.27, Coordination of
Emergency Response Planning?
SMSVP Standard: 5.21(a)
Do your safety management processes require
your safety policy be:
Signed by your accountable executive
(described in 5.25);
Documented and communicated throughout
your organization; and
Regularly reviewed by your accountable
executive to ensure it remains relevant and
appropriate to your organization?
SMSVP Standard: 5.21(b); 5.21(c) & 5.21(d)
Element - Safety Accountability and

Authority
Process Objectives
means to define accountability for safety for all
employees within their area of responsibility, and
identify authority for safety risk acceptance.
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SMSVP Requirement
Does your safety management policy define
accountability for safety for all personnel,
specifically:
Your accountable executive SMSVP Standard
5.25;
All members of management in regard to
developing, implementing, and maintaining SMS
processes within their area of responsibility; and
Employees relative to your organization's safety
performance?
SMSVP Standard: 5.23(a)(1); 5.23(a)(2) & 5.23(a)
(3)
Process Objectives
means to designate the accountable executive,
define responsibilities of the accountable
executive and senior management with respect to
a properly functioning SMS.
SMSVP Requirement
Does your organization identify an accountable
executive who, irrespective of other functions,
satisfies the following:
Is the final authority over operations authorized
to be conducted under your certificate(s);
Controls the financial resources required for the
operations to be conducted under your
certificate(s);
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Controls the human resources required for the
operations authorized to be conducted under your
certificate(s); and
Retains ultimate responsibility for the safety
performance of the operations conducted under
your certificate(s)?
In your safety management processes, is your
accountable executive required to accomplish the
following:
Ensure that your SMS is properly implemented
and performing in all areas of the organization;
Develop and sign your safety policy;
Communicate your safety policy throughout the
organization;
Regularly review your safety policy to ensure it
remains relevant and appropriate to your
organization; and
Regularly review the safety performance of your
organization and direct actions necessary to
address substandard safety performance in
accordance with SMSVP Standard 5.75,
Continuous Improvement?
SMSVP Standard: 5.25(b)
Element - Designation &

Responsibility of Required Safety
Management Personnel
Process Objectives
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means to designate the accountable executive,
define responsibilities of the accountable
executive and senior management with respect to
a properly functioning SMS.
SMSVP Requirement
Does your safety policy require all members of
management to develop, implement and maintain
SMS processes within their area of responsibility
to include, but not limited to, the following:
Hazard identification and safety risk assessment
Assuring the effectiveness of safety risk
controls;
Promoting safety as required of the SMSVP
Standard, subpart E, Safety Promotion; and
Advising your accountable executive on the
performance of the SMS and on any need for
improvement?
(Note: The questions above include owners
of operational processes (Managers,
Directors, etc.), at the decisional level across
the organization.)
SMSVP Standard: 5.23(a)(2)
Does your safety management processes identify
the levels of management with the authority to
make decisions regarding safety risk acceptance
for the company?
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(Note(s): This question/process includes

owners of operational processes (Managers,
the organization.)
Documentation Definition (reference FAA VS
Order 8000.367) - Information or meaningful
data and its supporting medium (e.g., paper,
electronic) that is distinct from records
because it is the written description of
policies, processes, procedures, objectives,
requirements, authorities, responsibilities, or
work instructions.)
Do your safety management processes require
your accountable executive to designate a
management representive who, on behalf of your
accountable executive, is responsible for:
Coordinating the implementation, maintenance,
and integration of the SMS throughout your
organization;
Facilitating hazard identification and safety risk
analysis;
Monitoring effectiveness of safety risk controls;
and
Ensure safety promotion is communicated
throughout your organization;
Regularly report to your accountable executive
on the performance of the SMS and any need for
improvement?
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(Note(s): The above qustion includes safety

support personnel such as a Safety Officer,
Director of Safety, Safety Department, etc.,
and associated staff.)
SMSVP Standard: 5.25(c)
Element - Coordination of Emergency

Response Planning
Process Objectives
means to develop and the accountable executive
must approve an emergency response plan. This
plan must delegate emergency authority
throughout your organization, assign employee
responsibilities during the emergency and
coordinate your plans with organizations you
interface with when you provide services.
SMSVP Requirement
Where emergency response procedures are
necessary, do you develop and does your
accountable executive and management
representative approve, as part of the safety
policy, an emergency response plan that provides
for the safe transition from normal to emergency
operations, and that addresses at least the
following:
Delegation of emergency authority throughout
your organization;
Assignment of employee responsibilities during
an emergency; and
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Coordination of the emergency response plan

with other affected organizations (e.g., code
share partners, airports, contractors, affiliates,
etc.)?
SMSVP Standard: 5.21(a)(6); 5.27(a); 5.27(b) &
5.27 (c )
Element - SMS Documentation

Process Objective
To provide the organizations decision makers
have a means to ensure that you have
documented safety policies; SMS processes and
procedures.
(Note(s): Documentation Definition (reference
FAA VS Order 8000.367) - Information or
meaningful data and its supporting medium
(e.g., paper, electronic) that is distinct from
records because it is the written description
of policies, processes, procedures,
objectives, requirements, authorities,
responsibilities, or work instructions.)
SMSVP Requirement
Do you have a process to develop and maintain
SMS documentation that describes your safety
policy, processes and procedures?
SMSVP Standard: 5.95(a) & 5.21 (c)
Does your safety management system ensure
compliance with the relevant regulatory standards
in 14 CFR?
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Component - Safety Risk

Management
Process Objective
means to understand the critical characteristics of
their systems and apply this knowledge to identify
hazards, analyze and assess risk and design risk
controls when designing, revising, or developing
operational changes, or when identifying a new
hazard or ineffective risk controls.
SMSVP Requirement
safety risk management component that is in
accordance with SMSVP Standard, subpart C,
Safety Risk Management?
Safety Risk Management Component in its
entirety and is best answered after
responding to all other questions within this
component.
Your Continuous Analysis and Surveillance
System (CASS) processes should be reviewed
when you identify risk in the SMS Safety Risk
Management and/or the SMS Safety
Assurance Components.)
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Element - Applicability
SMSVP Requirement
Does your safety management system require
that the safety risk management process be used
when any of the following conditions occur in your
operational processes:
Implementation of new systems;
Revision of existing systems;
Development of operational procedures; and
Identification of hazards or ineffective risk
controls identified through your safety assurance
processes contained within the SMSVP Standard,
subpart D, Safety Assurance?
SMSVP Standard: 5.51
Does your safety management system define
accountability for developing, implementing and
maintaining hazard identification and risk
assessment processes for each of your
operational manager's in their areas of
responsibility?
the organization.)
SMSVP Standard: 5.23(a)(2)(i)
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Does your safety management documentation

identify the levels of management with the
authority to make decisions regarding safety risk
acceptance for the company?
the organization.
Documentation Definition (reference FAA VS
Order 8000.367) - Information or meaningful
data and its supporting medium (e.g., paper,
electronic) that is distinct from records
because it is the written description of
policies, processes, procedures, objectives,
requirements, authorities, responsibilities, or
work instructions.)
Does your safety management system ensure
that your accountable executive designates a
management representative to facilitate hazard
identification and safety risk analysis?
safety support personnel such as a Safety
Officer, Director of Safety, Safety Department,
etc., and associated staff.)
SMSVP Standard: 5.25(c)(2)
Element - System Analysis & Hazard

Identification
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Process - System Analysis
Process Objectives
Process Objectives. To provide the organizations
decision makers a means to describe and
analyze its systems, operations, and operational
environment to gain an understanding of critical
design and performance factors, processes, and
activities in order to identify hazards.
SMSVP Requirement
When applying safety risk management, do you
have a process to describe and analyze the
system for use in identifying hazards, and does
this system analysis consider the following
information:
Function and purpose of the system;
The system's operating environment;
An outline of the system's processes and
procedures;
The personnel, equipment, and facilities
necessary for operating the system?
SMSVP Standard: 5.53(a) & 5.53(b)
Process - Hazard Identification

Process Objective
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means to identify and document hazards to your
operations, in the context of your system analysis,
that are likely to cause death, serious physical
harm, or damage to aircraft, aviation equipment
or property.
SMSVP Requirement
Does the safety risk management component of
your safety management system ensure that
processes to identify hazards within the context of
your system analysis are developed and
maintained?
SMSVP Standard: 5.53(c)
Element - Safety Risk Assessment and

Control
Process - Analyze Safety Risk
Process Objective
means to determine and analyze the severity and
likelihood of potential events associated with
identified hazards, and consider the risk factors
associated with severity and likelihood..
SMSVP Requirement
your safety management system ensure that
processes are developed and maintained to
analyze safety risk associated with identified
hazards?
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Process - Safety Risk Assessment

Process Objective
To provide the organizations authorized decision
makers a means to define and assess the risk
associated with each identified hazard to
determine if the risks are acceptable or not.
SMSVP Requirement
your safety management system define a process
for conducting risk assessments that allows for
the determination of acceptable safety risk?
Process - Safety Risk Control

Process Objective
means to develop and maintain risk control(s) for
each identified hazard with unacceptable risk to
reduce the risk to an acceptable level. You must
evaluate whether the risk will be acceptable with
the proposed risk control applied before
implementing the risk control.
SMSVP Requirement
Do you have a process to ensure that risk
controls that are necessary as a result of your
safety risk assessment process are developed,
implemented and maintained?
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(Note(s): Implementation of controls should
include appropriate procedures, instructions
and/or methods.)
SMSVP Standard: 5.55(c) and 5.53(a)
Does your risk management process have
procedures to evaluate whether the risk will be
acceptable with the safety risk control applied
before the risk control is implemented?
SMSVP Standard: 5.55 (d)
process to ensure implemented risk controls are
evaluated in the safety assurance component to
identify ineffective controls?
Element - SMS Documentation and

Recordkeeping (SRM)
Process Objective
means to ensure that you have documented
safety policies, SMS processes and procedures,
and that a document/record management
process is established and maintained that
records SRM outputs.
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risk management processes and procedures?
Do you have a process to maintain records of
safety risk management outputs for as long as
the controls remain relevant to your operations?
Component - Safety Assurance

Process Objective
means obtain timely feedback on the status,
performance, and potential problems associated
with processes in their area of responsibility.
Safety assurance will monitor, measure, and
evaluate your safety performance and the
effectiveness of your risk controls.
SMSVP Requirement
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safety assurance component that is in
accordance with the SMSVP Standard, Subpart
D, Safety Assurance?
Safety Assurance Component in its entirety
and is best answered after responding to all
other questions within this component.
Your Continuous Analysis and Surveillance
System (CASS) processes should be reviewed
when you identify risk in the SMS Safety Risk
Management and/or the SMS Safety
Assurance Components.)
Element - Safety Performance

Monitoring and Measurement
Process - Continuous Monitoring
Process Objective
means to monitor and gather data with respect to
operations, operational processes, and the
operational environment. This includes products
and services, identifying hazards, measuring the
effectiveness of safety risk controls, and
monitoring the safety performance of your
organization.
SMSVP Requirement
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Does your safety management system develop

and maintain processes and systems to acquire
data with respect to its operations, products, and
services to monitor the safety performance of the
organization to include:
continuous monitoring of operational processes,
periodic moitoring of the operational
environment to detect changes?
SMSVP Standard: 5.71(a)(1) & 5.71(a)(2)
Process - Auditing
Process Objective
means to gather data with respect to operations,
products and services, and monitoring the safety
performance of your organization through audits
of operational processes and systems.
SMSVP Requirement
data with respect to your operations, products,
and services to monitor the safety performance of
your organization to include auditing your
operational processes and systems?
Process - Evaluations
Process Objective
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performance of your organization through
evaluations of the SMS and operational
processes and systems.
SMSVP Requirement
data with respect your operations, products, and
services to monitor the safety performance of
your organization to include evaluations of:
Your SMS
Your operational process and systems?
Process - Investigations
Process Objective
performance of your organization through
investigation of incidents, accidents, potential
non-compliance with regulatory standards or
other safety risk controls established through your
safety risk management process.
SMSVP Requirement
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and services to monitor safety performance to
include investigating the following :
Incidents and accidents,
Reports regarding potential non-compliance with
regulatory standards or other safety risk controls
established through your SRM process?
SMSVP Standard: 5.71(a)(5) & 5.71(a)(6)
Process - Confidential Employee

Reporting System
Process Objective
performance of your organization through a
confidential employee reporting system in which
employees can report hazards, issues, concerns,
occurrences, incidents, as well as propose
solutions and safety improvements.
SMSVP Requirement
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and services to monitor the safety performance to
include a confidential employee reporting
system in which employees can report hazards,
issues, concerns, occurrences, incidents, as well
as propose solutions and safety improvements?
Process - Analyze Data

Process Objective
means to analyze data with respect to operations,
products and services. This analysis will monitor
the safety performance of your organization
through audits, evaluations, investigations, and
employee reports, and any other relevant data
with respect to your operations, products, and
services.
SMSVP Requirement
Have you developed, and do you maintain
procedures to analyze data acquired from your
safety assurance monitoring and measurement
processes (the above five processes) and other
relevant data from your operations, products and
services?
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Process - Safety Performance
Assessment
Process Objective
means to conduct assessments, including
reviews by the accountable executive, of safety
performance against safety objectives and to
ensure compliance with safety risk controls. You
must evaluate the performance of your SMS,
evaluate the effectiveness of safety risk controls,
identify ineffective controls or new hazards, and
identify changes in your operation. Ineffective
controls or new hazards must be addressed
through the SRM process.
SMSVP Requirement
Do you have documented processes to assess
safety performance against your safety
performance objectives that include reviews by
your accountable executive to:
Ensure compliance with your established safety
risk controls;
Evaluate the performance of your safety
management system;
Evaluate the effectiveness of your safety risk
controls establlished under your SRM and identify
any ineffective controls;
Identify changes in your operational
environment that may introduce new hazards,
Identify new hazards?
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SMSVP Standard: 5.73(a) & 5.25(b)(5)

Does your safety management processes ensure
that the accountable executive designate a
management representative who, on behalf your
accountable executive, monitors the effectiveness
of your safety risk controls?
SMSVP Standard: 5.25(c)(3):
Does your safety management system define
accountability for assuring the effectiveness of
safety risk controls for all your managers in their
areas of responsibility?
the organization.)
SMSVP Standard: 5.23(a)(2)(ii)
Do you have procedures to ensure you address in
your safety risk management process any
ineffective controls, new hazards or potential
hazards identified during safety performance
assessments (conducted as part of your safety
assurance process)?
Element - Continuous Improvement
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Process Objective
means to correct safety performance deficiencies
identified in your safety performance assessment
process.
SMSVP Requirement
Does your safety management have process to
correct safety performance deficiencies identified
during your safety performance assessments
(conducted as part of your safety assurance
process)?
SMSVP Standard: 5.75 & 5.25(b)(5)
Does your safey management have processes to
ensure your accountable executive directs actions
necessary to address substandard safety
performance?
SMSVP Standard: 5.75 & 5.25(b)(5)

Recordkeeping (SA)
Process Objective
means to ensure that you have documented
safety policies, SMS processes and procedures,
and that a document/record management
process is established and maintained that
records SA outputs.
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assurance processes and procedures?
Do you have procedures to maintain records of
outputs of the safety assurance processes for a
minimum of 5 years?
SMSVP Standard: 5.97(b) and 5.3 (b)
Component - Safety Promotion

Safety Promotion: General
Expectations
Process Objective
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To provide your accountable executive and the

organizations decision makers a means to
promote the growth of a positive safety culture,
attain and maintain employee competencies
necessary to perform their duties relevant to your
operation and performance of the SMS, provide
employees with effective SMS training, and a
means to receive organization wide safety
communication.
SMSVP Requirement
safety promotion component that is in accordance
with SMSVP Standard, Subpart E, Safety
Promotion?
Safety Promotion Component in its entirety
and is best answered after responding to all
other questions within this component.)
Do your safety management processes ensure
that the accountable executive designates a
management representative, who on behalf of the
accountable executive, is responsible for ensuring
safety promotion throughout your organization?
SMSVP Standard: 5.25(c)(4)
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Does your organizations safety management

system define accountability for promoting safety
for each operational manager in their areas of
responsibility?
the organization.)
SMSVP Standard: 5.23 (a) (2) (iii)
Element - Competencies and Training

Process Objective
means to train employees so they are competent
in the performance of their SMS related duties.
(Note: In order to attain and maintain
competencies necessary for their position,
you must first identify the competencies
required for each position.)
SMSVP Requirement
process to ensure that your organization provides
training to each individual identified in 5.23 to
ensure the individuals attain and maintain the
competencies necessary to perform their duties
relevant to the operation and performance of the
SMS?
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NPRM GAP Analysis

Questions
(Note(s): Competence can be assessed at the

completion of training by written, oral, or
demonstration tests, and then measured
periodically during the performance of that
individuals work by way of periodic
evaluations or supervisor/management
observations (reference AC 120-92).)
Element - Safety Communication

Process Objective
means to communicate safety information
SMSVP Requirement
Does your safety management have processes
and does it maintain process and systems to
communicate safety information that:
Ensures that employees are aware of the SMS;
Conveys safety critical information;
Explains why safety actions have been taken;
and
Explains why safety procedures are introduced
or changed?

Recordkeeping (Promotion)
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Questions
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promotion processes and procedures?
SMSVP Standard: 5.95(b) & 5.3 (b)
Do you have processes to maintain records of all
SMS training accomplished for each individual for
a minimum period of 24 consecutive calendar
months after the completion of training?
SMSVP Standard: 5.97(c) & 5.3(b)
Do you have a process to retain the records of all
SMS safety communications for a minimum of 24
consecutive calendar months?
SMSVP Standard: 5.97 (d) & 5.3(b)
NOTE:
To be considered for acceptance by your CMT, each requirement of this SMS gap analysis should have a validated assessment
scale rating of Accomplished or Demonstrated.
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Questions
Assessment Level
Not Performed
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Assessment Rating Scale

Word Picture
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Assessment Scale
No action has been taken on this

requirement
NP
A plan exists with actions to be taken or

manual/s affected, a scheduled completion
date and responsible individual or group
identified to meet this requirement.
PLN
The policy and procedural guidance of this

requirement are incorporated into company
documents such as manuals, training
material, and work instructions.
DOC
Resources are in place to accomplish all

objectives of this requirement. Employees
are expected to be trained and
knowledgeable on the policies and
procedures which were documented in the
previous assessment level (DOC).
ACC
Planned
Documented**
Accomplished**
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Demonstrated**
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Company's
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This requirement of your companys SMS

has been subjected to at least one round of
evaluation/auditing by your company (and
validated by the CMT/CHDO) to demonstrate
operational performance and
Cabin
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DEM
** = These assessments require oversight organization (CMT, CHDO, etc.) validation.
Page 32 of 32
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NPRM GAP Analysis

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Element - Safety Policy

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Element - Safety Accountability and

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NPRM GAP Analysis

Element - Designation &

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NPRM GAP Analysis

To provide the organizations decision makers a

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(Note(s): This question/process includes

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(Note(s): The above qustion includes safety

Element - Coordination of Emergency

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NPRM GAP Analysis

Coordination of the emergency response plan

Element - SMS Documentation

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NPRM GAP Analysis

SMSVP Standard: 5.3(b)

Component - Safety Risk

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NPRM GAP Analysis

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NPRM GAP Analysis

Does your safety management documentation

Element - System Analysis & Hazard

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NPRM GAP Analysis

Process - Hazard Identification

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NPRM GAP Analysis

To provide the organizations decision makers a

Element - Safety Risk Assessment and

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NPRM GAP Analysis

SMSVP Standard: 5.55(a)

Process - Safety Risk Assessment

Process - Safety Risk Control

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NPRM GAP Analysis

Element - SMS Documentation and

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NPRM GAP Analysis

(Note(s): Documentation Definition (reference

Component - Safety Assurance

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NPRM GAP Analysis

Does your safety management system have a

Element - Safety Performance

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NPRM GAP Analysis

Does your safety management system develop

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