3.SMS Manual PDF

PRELIMINARY PAGES P: AA-2
AUTHORITY APPROVAL Rev. 00, 10 JAN 2017
Intentionally Blank
SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

PRELIMINARY PAGES P: DCL-1
DISTRIBUTION CONTROL LIST Rev. 00, 10 JAN 2017
DISTRIBUTION CONTROL LIST

The following title holders or office shall receive a hard copy of the Safety Management
System Manual (SMS Manual) and the subsequent revisions:
No. Document Control No. Holder
1. JC/SMS/001 JC Master
2. JC/SMS/002 SSCA – Phnom Penh
3. JC/SMS/003 Accountable Manager
4. JC/SMS/004 Safety Manager
5. JC/SMS/005 Quality Assurance Director
6. JC/SMS/006 Flight Safety Officer
7. JC/SMS/007 Company Library
Hard copies shall be printed in A4 or A5 size.

PRELIMINARY PAGES P: DCL-2
DISTRIBUTION CONTROL LIST Rev. 00, 10 JAN 2017
Intentionally Blank

PRELIMINARY PAGES P: RoR-1
RECORD OF REVISIONS Rev. 00, 10 JAN 2017
RECORD OF REVISIONS
Safety Management System Manual (SMS Manual), its amendments and revisions, are
published and issued by the JC Cambodia International Airlines (JC Airlines) Safety
Department. Safety Manager is responsible for its contents, and for keeping the
instructions and information up-to-date. Manuals and revisions have to be approved by the
State Secretariat of Civil Aviation (SSCA) in advance of the issue date.
Hard copy and the subsequent revisions will be issued to authorized holders (refer to
Distribution Control List). A copy of SMS Manual will be available to all operations
personnel in electronic format. Revisions will be issued to operations personnel and
relevant sub-contractors in the form of a new disk or file containing the complete manual.
Revisions will be issued at irregular intervals and sent to all authorized holders of the
manual. Revisions will be numbered consecutively and shall be entered in the revision
record sheet below to ensure that the manual is up-to-date; the compliance is confirmed
when signed under “Signature”. Revisions shall be inserted by all authorized users without
delay. A break in the numbers may indicate that a particular revision has not been
received, and the holder of the manual shall immediately request the missing revision
through Flight Operations Department.
Each revision will include detailed instructions sheet, which shall be used to check the
completeness of the respective revision. If any page is found to be missing, Flight
Operations Department shall be notified immediately.
Hand written amendments and revisions are not permitted except in situations requiring
immediate amendment or revision in the interest of safety.

PRELIMINARY PAGES P: RoR-2
RECORD OF REVISIONS Rev. 00, 10 JAN 2017
Entered by
Revision No Effective Date Revision Date Insertion Date
(Signature)
00 10 FEB 2017 10 JAN 2017
RETAIN THIS SHEET UNTIL REPLACED WITH NEW ISSUE

PRELIMINARY PAGES P: RoARA-1
RECORD OF AUTHORITY REVISION APPROVALS Rev. 00, 10 JAN 2017
RECORD OF AUTHORITY REVISION APPROVALS
Revision No Revision Date Authority Approval Signature Date
00 10 JAN 2017

PRELIMINARY PAGES P: RoARA-2
RECORD OF AUTHORITY REVISION APPROVALS Rev. 00, 10 JAN 2017

PRELIMINARY PAGES P: RoTR-1
RECORD OF TEMPORARY REVISIONS Rev. 00, 10 JAN 2017
RECORD OF TEMPORARY REVISIONS

Temporary Revisions to this manual will be issued at irregular intervals. Temporary
Revisions will be issued on yellow pages and are to be inserted facing the appropriate
revisions on white pages. Do not remove white pages unless specified to do so.
List of Temporary Revisions

Inserted/Deleted
TR No Page Chapter Rev Date Status
Date By

PRELIMINARY PAGES P: RoTR-2
RECORD OF TEMPORARY REVISIONS Rev. 00, 10 JAN 2017
Intentionally Blank

PRELIMINARY PAGES P: RoATRA-1
RECORD OF AUTHORITY TEMPORARY REVISION APPROVALS Rev. 00, 10 JAN 2017
RECORD OF AUTHORITY TEMPORARY REVISION APPROVALS

PRELIMINARY PAGES P: RoATRA-2
RECORD OF AUTHORITY TEMPORARY REVISION APPROVALS Rev. 00, 10 JAN 2017
Intentionally Blank

PRELIMINARY PAGES P: RH-1
REVISION HIGHLIGHTS Rev. 00, 10 JAN 2017
REVISION HIGHLIGHTS
Revision 00, 10 January 2017.
Reason for issue: New document.

PRELIMINARY PAGES P: RH-2
REVISION HIGHLIGHTS Rev. 00, 10 JAN 2017
Intentionally Blank

PRELIMINARY PAGES P: LEP-1
LIST OF EFFECTIVE PAGES Rev. 00, 10 JAN 2017
LIST OF EFFECTIVE PAGES
Page Revision Date

AA-1 00 10 JAN 2017
AA-2 00 10 JAN 2017
DCL-1 00 10 JAN 2017
DCL-2 00 10 JAN 2017
RoR-1 00 10 JAN 2017
RoR-2 00 10 JAN 2017
RoARA-1 00 10 JAN 2017
RoARA-2 00 10 JAN 2017
RoTR-1 00 10 JAN 2017
RoTR-2 00 10 JAN 2017
RoATRA-1 00 10 JAN 2017
RoATRA-2 00 10 JAN 2017
RH-1 00 10 JAN 2017
RH-2 00 10 JAN 2017
LEP-1 00 10 JAN 2017
LEP-2 00 10 JAN 2017
LEP-3 00 10 JAN 2017
LEP-4 00 10 JAN 2017
LEP-5 00 10 JAN 2017
LEP-6 00 10 JAN 2017
MI-1 00 10 JAN 2017
MI-2 00 10 JAN 2017
ToC-1 00 10 JAN 2017
ToC-2 00 10 JAN 2017
ToC-3 00 10 JAN 2017
ToC-4 00 10 JAN 2017
0-1 00 10 JAN 2017
0-2 00 10 JAN 2017
0-3 00 10 JAN 2017
0-4 00 10 JAN 2017
0-5 00 10 JAN 2017
0-6 00 10 JAN 2017
0-7 00 10 JAN 2017
0-8 00 10 JAN 2017
0-9 00 10 JAN 2017
0-10 00 10 JAN 2017

Page Revision Date

0-11 00 10 JAN 2017
0-12 00 10 JAN 2017
0-13 00 10 JAN 2017
0-14 00 10 JAN 2017
0-15 00 10 JAN 2017
0-16 00 10 JAN 2017
1-1 00 10 JAN 2017
1-2 00 10 JAN 2017
1-3 00 10 JAN 2017
1-4 00 10 JAN 2017
1-5 00 10 JAN 2017
1-6 00 10 JAN 2017
1-7 00 10 JAN 2017
1-8 00 10 JAN 2017
1-9 00 10 JAN 2017
1-10 00 10 JAN 2017
1-11 00 10 JAN 2017
1-12 00 10 JAN 2017
1-13 00 10 JAN 2017
1-14 00 10 JAN 2017
1-15 00 10 JAN 2017
1-16 00 10 JAN 2017
1-17 00 10 JAN 2017
1-18 00 10 JAN 2017
1-19 00 10 JAN 2017
1-20 00 10 JAN 2017
1-21 00 10 JAN 2017
1-22 00 10 JAN 2017
1-23 00 10 JAN 2017
1-24 00 10 JAN 2017
1-25 00 10 JAN 2017
1-26 00 10 JAN 2017
1-27 00 10 JAN 2017
1-28 00 10 JAN 2017
1-29 00 10 JAN 2017
1-30 00 10 JAN 2017
1-31 00 10 JAN 2017
1-32 00 10 JAN 2017

Page Revision Date

1-33 00 10 JAN 2017
1-34 00 10 JAN 2017
1-35 00 10 JAN 2017
1-36 00 10 JAN 2017
1-37 00 10 JAN 2017
1-38 00 10 JAN 2017
1-39 00 10 JAN 2017
1-40 00 10 JAN 2017
1-41 00 10 JAN 2017
1-42 00 10 JAN 2017
1-43 00 10 JAN 2017
1-44 00 10 JAN 2017
1-45 00 10 JAN 2017
1-46 00 10 JAN 2017
1-47 00 10 JAN 2017
1-48 00 10 JAN 2017
1-49 00 10 JAN 2017
1-50 00 10 JAN 2017
1-51 00 10 JAN 2017
1-52 00 10 JAN 2017
2-1 00 10 JAN 2017
2-2 00 10 JAN 2017
2-3 00 10 JAN 2017
2-4 00 10 JAN 2017
2-5 00 10 JAN 2017
2-6 00 10 JAN 2017
2-7 00 10 JAN 2017
2-8 00 10 JAN 2017
2-9 00 10 JAN 2017
2-10 00 10 JAN 2017
2-11 00 10 JAN 2017
2-12 00 10 JAN 2017
2-13 00 10 JAN 2017
2-14 00 10 JAN 2017
2-15 00 10 JAN 2017
2-16 00 10 JAN 2017
2-17 00 10 JAN 2017
2-18 00 10 JAN 2017

Page Revision Date

2-19 00 10 JAN 2017
2-20 00 10 JAN 2017
2-21 00 10 JAN 2017
2-22 00 10 JAN 2017
2-23 00 10 JAN 2017
2-24 00 10 JAN 2017
2-25 00 10 JAN 2017
2-26 00 10 JAN 2017
3-1 00 10 JAN 2017
3-2 00 10 JAN 2017
3-3 00 10 JAN 2017
3-4 00 10 JAN 2017
3-5 00 10 JAN 2017
3-6 00 10 JAN 2017
3-7 00 10 JAN 2017
3-8 00 10 JAN 2017
3-9 00 10 JAN 2017
3-10 00 10 JAN 2017
3-11 00 10 JAN 2017
3-12 00 10 JAN 2017
3-13 00 10 JAN 2017
3-14 00 10 JAN 2017
3-15 00 10 JAN 2017
3-16 00 10 JAN 2017
3-17 00 10 JAN 2017
3-18 00 10 JAN 2017
3-19 00 10 JAN 2017
3-20 00 10 JAN 2017
3-21 00 10 JAN 2017
3-22 00 10 JAN 2017
3-23 00 10 JAN 2017
3-24 00 10 JAN 2017
3-25 00 10 JAN 2017
3-26 00 10 JAN 2017
3-27 00 10 JAN 2017
3-28 00 10 JAN 2017
3-29 00 10 JAN 2017
3-30 00 10 JAN 2017

Page Revision Date

3-31 00 10 JAN 2017
3-32 00 10 JAN 2017
3-33 00 10 JAN 2017
3-34 00 10 JAN 2017
3-35 00 10 JAN 2017
3-36 00 10 JAN 2017
3-37 00 10 JAN 2017
3-38 00 10 JAN 2017
3-39 00 10 JAN 2017
3-40 00 10 JAN 2017
3-41 00 10 JAN 2017
3-42 00 10 JAN 2017
3-43 00 10 JAN 2017
3-44 00 10 JAN 2017
3-45 00 10 JAN 2017
3-46 00 10 JAN 2017
3-47 00 10 JAN 2017
3-48 00 10 JAN 2017
3-49 00 10 JAN 2017
3-50 00 10 JAN 2017
3-51 00 10 JAN 2017
3-52 00 10 JAN 2017
3-53 00 10 JAN 2017
3-54 00 10 JAN 2017
3-55 00 10 JAN 2017
3-56 00 10 JAN 2017
3-57 00 10 JAN 2017
3-58 00 10 JAN 2017
3-59 00 10 JAN 2017
3-60 00 10 JAN 2017
3-61 00 10 JAN 2017
3-62 00 10 JAN 2017
3-63 00 10 JAN 2017
3-64 00 10 JAN 2017
3-65 00 10 JAN 2017
3-66 00 10 JAN 2017
3-67 00 10 JAN 2017
3-68 00 10 JAN 2017

Page Revision Date

3-69 00 10 JAN 2017
3-70 00 10 JAN 2017
4-1 00 10 JAN 2017
4-2 00 10 JAN 2017
4-3 00 10 JAN 2017
4-4 00 10 JAN 2017
4-5 00 10 JAN 2017
4-6 00 10 JAN 2017
4-7 00 10 JAN 2017
4-8 00 10 JAN 2017
5-1 00 10 JAN 2017
5-2 00 10 JAN 2017
5-3 00 10 JAN 2017
5-4 00 10 JAN 2017
5-5 00 10 JAN 2017
5-6 00 10 JAN 2017
5-7 00 10 JAN 2017
5-8 00 10 JAN 2017
6-1 00 10 JAN 2017
6-2 00 10 JAN 2017
6-3 00 10 JAN 2017
6-4 00 10 JAN 2017
6-5 00 10 JAN 2017
6-6 00 10 JAN 2017
6-7 00 10 JAN 2017
6-8 00 10 JAN 2017
6-9 00 10 JAN 2017
6-10 00 10 JAN 2017
6-11 00 10 JAN 2017
6-12 00 10 JAN 2017
6-13 00 10 JAN 2017
6-14 00 10 JAN 2017

PRELIMINARY PAGES P: MI-1
MASTER INDEX Rev. 00, 10 JAN 2017
MASTER INDEX
Reserved.

PRELIMINARY PAGES P: MI-2
MASTER INDEX Rev. 00, 10 JAN 2017
Intentionally Blank

PRELIMINARY PAGES P: ToC-1
TABLE OF CONTENTS Rev. 00, 10 JAN 2017
TABLE OF CONTENTS
AUTHORITY APPROVAL
DISTRIBUTION CONTROL LIST
RECORD OF REVISIONS
RECORD OF AUTHORITY REVISION APPROVALS
RECORD OF TEMPORARY REVISIONS
RECORD OF AUTHORITY TEMPORARY REVISION APPROVALS
REVISION HIGHLIGHTS
LIST OF EFFECTIVE PAGES
MASTER INDEX
TABLE OF CONTENTS
0 GENERAL INFORMATION .................................................................................................................. 0-1
0.1 Introduction ..................................................................................................................................... 0-1
0.2 Contents.......................................................................................................................................... 0-3
0.3 Organization and Identification ....................................................................................................... 0-4
0.3.1 Organization ....................................................................................................................... 0-4
0.3.2 Identification ....................................................................................................................... 0-4
0.4 Terminology .................................................................................................................................... 0-5
0.4.1 Terms ................................................................................................................................. 0-5
0.4.2 Synonyms ........................................................................................................................... 0-6
0.5 Abbreviations .................................................................................................................................. 0-7
0.6 Definitions ..................................................................................................................................... 0-11
1 SAFETY POLICY AND OBJECTIVES ................................................................................................. 1-1
1.1 Concept of Safety ........................................................................................................................... 1-1
1.2 Statutory Requirements .................................................................................................................. 1-2
1.3 Safety Policy ................................................................................................................................... 1-5
1.4 Safety Objectives and Goals .......................................................................................................... 1-8
1.5 JC Airlines’ Safety Culture ............................................................................................................ 1-11
1.6 Appointment of Key Safety Personnel .......................................................................................... 1-13
1.7 Safety Responsibilities and Accountabilities ................................................................................ 1-14
1.7.1 Management Responsibilities .......................................................................................... 1-14
1.7.2 Safety Department Organisation ...................................................................................... 1-15
1.7.3 Accountable Manager ...................................................................................................... 1-17
1.7.4 Safety Manager ................................................................................................................ 1-17
1.7.5 Flight Safety Officer .......................................................................................................... 1-21
1.7.6 Safety Review Committee ................................................................................................ 1-21
1.7.7 Safety Action Group ......................................................................................................... 1-22
1.7.8 All Personnel .................................................................................................................... 1-23
1.8 Emergency Response Plan .......................................................................................................... 1-25
1.8.1 General ............................................................................................................................. 1-25
1.8.2 The Coordination of the Emergency Response Plan ....................................................... 1-25
1.8.3 ERP Contents ................................................................................................................... 1-26
1.8.4 Aircraft Operator’s Responsibilities .................................................................................. 1-29
1.8.5 Checklists ......................................................................................................................... 1-30
1.8.6 Training and Exercises ..................................................................................................... 1-30

1.9 SMS Documentation ..................................................................................................................... 1-31

1.9.1 General ............................................................................................................................. 1-31
1.10 Understanding Safety ................................................................................................................... 1-32
1.10.1 Accident Causation........................................................................................................... 1-32
1.10.2 Human Factors ................................................................................................................. 1-33
1.10.2.1 Introduction .................................................................................................................. 1-33
1.10.2.2 The Meaning of Human Factors .................................................................................. 1-33
1.10.2.3 The SHEL Model ......................................................................................................... 1-34
1.10.2.4 The Aim of Human Factors ......................................................................................... 1-35
1.10.2.5 Safety and Efficiency ................................................................................................... 1-36
1.10.2.6 Factors Affecting Air Crew Performance ..................................................................... 1-37
1.10.2.7 Personality vs. Attitude ................................................................................................ 1-38
1.10.2.8 Crew Resource Management (CRM) .......................................................................... 1-39
1.10.3 Cultural Factors ................................................................................................................ 1-41
1.10.4 Corporate Safety Culture .................................................................................................. 1-42
1.10.5 Human Error ..................................................................................................................... 1-44
1.10.5.1 General ........................................................................................................................ 1-44
1.10.5.2 Error Types .................................................................................................................. 1-45
1.10.6 Bias ................................................................................................................................... 1-47
1.11 SMS Implementation Plan ............................................................................................................ 1-49
1.11.1 General ............................................................................................................................. 1-49
1.11.2 Overview of the SMS Implementation Plan ...................................................................... 1-49
2 SAFETY RISK MANAGEMENT ........................................................................................................... 2-1
2.1 General ........................................................................................................................................... 2-1
2.2 Hazard Identification ....................................................................................................................... 2-7
2.3 Safety Risk Assessment ............................................................................................................... 2-11
2.3.1 General ............................................................................................................................. 2-11
2.3.2 Safety Risk Probability ..................................................................................................... 2-12
2.3.3 Safety Risk Severity ......................................................................................................... 2-13
2.3.4 Safety Risk Tolerability ..................................................................................................... 2-14
2.4 Safety Risk Mitigation ................................................................................................................... 2-18
2.4.1 General ............................................................................................................................. 2-18
2.4.2 Safety Analysis ................................................................................................................. 2-22
2.4.2.1 General ........................................................................................................................ 2-22
2.4.2.2 Safety Database .......................................................................................................... 2-22
2.4.2.3 Bias.............................................................................................................................. 2-23
2.4.2.4 Analytical Methods and Tools ..................................................................................... 2-24
3 SAFETY ASSURANCE ........................................................................................................................ 3-1
3.1 General ........................................................................................................................................... 3-1
3.2 Safety Performance Monitoring and Measurement ........................................................................ 3-3
3.2.1 General ............................................................................................................................... 3-3
3.2.2 Safety Performance Indicators ........................................................................................... 3-4
3.2.3 Safety Audits .................................................................................................................... 3-13
3.2.4 Safety Reviews ................................................................................................................. 3-18
3.2.5 Safety Surveys ................................................................................................................. 3-18
3.2.6 Safety Investigations ........................................................................................................ 3-19
3.2.7 Flight Data Monitoring (FDM) ........................................................................................... 3-20
3.2.7.1 General ........................................................................................................................ 3-20
3.2.7.2 FDM Programme ......................................................................................................... 3-25
3.2.7.3 Organisation and Control of FDM Information ............................................................ 3-34
3.2.7.4 FDM Reports ............................................................................................................... 3-40

3.2.7.5 FDM Confidentiality Agreement .................................................................................. 3-41

3.2.7.6 FDM and Mandatory Occurrence Reporting ............................................................... 3-45
3.2.8 Line Operations Safety Audits .......................................................................................... 3-46
3.2.9 Cabin Safety ..................................................................................................................... 3-51
3.2.10 Occurrence Reporting ...................................................................................................... 3-54
3.2.10.1 General ........................................................................................................................ 3-54
3.2.10.2 Mandatory Occurrence Report .................................................................................... 3-56
3.2.10.3 Voluntary/Confidential Occurrence Report.................................................................. 3-58
3.3 Management of Change ............................................................................................................... 3-61
3.4 Continuous Improvement of the SMS ........................................................................................... 3-64
3.5 Corrective and Preventive Action ................................................................................................. 3-67
3.5.1 General ............................................................................................................................. 3-67
3.5.2 Corrective Action .............................................................................................................. 3-67
3.5.3 Preventive Action.............................................................................................................. 3-68
3.6 SMS and QMS .............................................................................................................................. 3-69
4 SAFETY PROMOTION ......................................................................................................................... 4-1
4.1 General ........................................................................................................................................... 4-1
4.2 Safety Training and Education........................................................................................................ 4-2
4.2.1 General ............................................................................................................................... 4-2
4.2.2 Safety Management System Training ................................................................................ 4-2
4.2.3 Initial Safety Management System Training for all Personnel ........................................... 4-3
4.2.4 Training for Management Team ......................................................................................... 4-4
4.2.5 Specialist Safety Training ................................................................................................... 4-4
4.2.6 Safety Training for Operations Personnel .......................................................................... 4-4
4.2.7 Safety Manager Training .................................................................................................... 4-5
4.3 Safety Communication .................................................................................................................... 4-6
5 OCCURRENCE REPORTING FORMS ................................................................................................ 5-1
5.1 Air Safety Report (ASR).................................................................................................................. 5-1
5.2 Occurrence Report ......................................................................................................................... 5-3
5.3 Dangerous Goods Occurrence Report ........................................................................................... 5-4
5.4 Ground (Incident/Accident) Damage Report .................................................................................. 5-6
6 LOSA OBSERVATION FORM ............................................................................................................. 6-1

Intentionally Blank

CHAPTER 0 P: 0-1
GENERAL INFORMATION Rev. 00, 10 JAN 2017
0 GENERAL INFORMATION
0.1 INTRODUCTION
The Safety Management System Manual (SMS Manual) describes JC Cambodia

International Airlines (JC Airlines) safety policies, methods and procedures for SMS
implementation and operation within JC Airlines.
The purpose of this manual is to assist all those who work at or work with JC Airlines in
fulfilling its requirements with respect to the implementation of SMS. Application of the
guidance material herein is not limited to operation personnel. Rather, it is relevant to the
full spectrum of personnel and organisations in connection with the aviation safety.
This manual is in particular aimed at the personnel who are responsible for designing,
implementing and managing effective safety activities, namely:
• JC Airlines officials with responsibilities for regulating the aviation system
management of operational organizations (subcontractors);
• Safety practitioners, such as Safety Manager.
Users should find sufficient information herein for justification, initiation and operation of a
viable SMS.
This manual together with other manuals, JC Airlines acceptable standards and
operational procedures, builds up a comprehensive documentation system which is the
key of an effective safety management system.
Documentation system of JC Airlines in general and this manual in particular is reviewed

annually and continuously improved to adapt to the most current SSCA requirements and
other related requirements.
Safety management is the process through which JC Airlines delivers safe, reliable,
efficient and predictable operational performance.
SMS Manual contains significant and pertinent information on the safety of JC Airlines and
is to be used as a guide for all employees of the company, its aviation subsidiaries and its
third party outsourced contractors when carrying out their assigned duties for JC Airlines.
It shall be noted that it is also the intention of this manual to uphold and support the
relevant laws and regulatory requirements. Should any policy or information contained in
this manual contradict any of laws or regulatory requirements, the laws or regulatory
requirements shall take precedence. The inconsistencies should be notified as soon as
possible to the Safety Manager.

CHAPTER 0 P: 0-2
Safety management is supported through an SMS framework which goes beyond the
traditional approach of compliance, with prescriptive regulations, to include safety
performance; a systematic and integrated approach established on evidence-based data
and controls.
SMS Manual is intended as a guide in planning and operating a comprehensive safety

program throughout the spectrum of JC Airlines operations specially, oriented and focused
to aspects of safety as they apply to its air operations.
However, in respect of the maxim that no weakness in a system, especially in aviation,

would remain unconnected with others and occurs in isolation, all aspects of safety, in
every activity and work process be it in the apron, office, hangar, workshops or in the air
shall be guided by the frame-work of the principles and concepts enumerated in this
manual. Also to be acknowledged is the fact that this manual would not claim to cover in
minutest detail every safety aspect that is intrinsic and basic to work processes and
functions of every section and department of the company. Therefore, emphasis is placed
on the independence and authority of safety function in each cell of the company and its
supervisory person.
However all aspects of safety function should comply with the overarching safety principles
and standards of the company, the industry and the regulatory requirements and thus are
and should be subjected to evaluations, assessments, inspections, audits and reviews.
Suggestions for improving the contents of this document are always welcomed. Subtle
changes to air traffic clearances, weather reporting procedures, preferred alternates etc.
are not always provided in a timely manner. The Journey Log Report is the prime means
of reporting operational problems and changes. This form will facilitate appropriate
corrective action for those items of a more general nature, and it can also be used to
provide appropriate amendment action to the Operations Manual.
Responsibility for the contents of this manual and their proper implementation rests with
the Safety Manager. The distribution of content of the SMS Manual to unauthorized
persons is strictly prohibited.
The SMS Manual is written in English language, and printed in legible fonts.
The underlying principal of this manual is to promote best practices in all aspects of JC
Airlines operations. However, the success in implementing safety measures and standards
is not just the responsibility of Safety Department alone but must be shared with all in the
Company.
It is hoped that all staff will be made conversant and will comply with the stated policies
and procedures herein.

CHAPTER 0 P: 0-3
0.2 CONTENTS
This Manual is structured in accordance with SMS structure, as described in ICAO Doc
9895 Safety Management System. The main components of the SMS are as follows and
are described in detail throughout the manual:
• Safety Policy and Objectives;
• Safety Risk Management;
• Safety Assurance;
• Safety Promotion.
Detailed references regarding the contents of this manual may be found in Table of
Contents.
The elements of Safety Program this manual addresses:

• Senior management commitment to JC Airlines safety program;
• Establishment and functions of Safety Department under the Safety Manager;
• Promotion of positive safety culture across the board in JC Airlines;
• Building a safety management structure;
• Identification of hazards, risks, unsafe conditions, negative attitudes to safety and
areas where there is space for safety improvement;
• Establishing and operating an active hazard reporting system;
• Safety audits assessment of standards and compliance;
• Developing an effective unplanned and unanticipated occurrence (incidents and
accidents) reporting and investigation system;
• Implementation of a digital flight data recorder information monitoring and
evaluation system;
• Participation in information exchange within and without the industry in respect of
loss control occurrences and the corrective actions taken;
• Integrating safety principles, practices and concepts in all trainings;
• Human factors;
• Promoting a culture of expressing thoughts and ideas free from negative
constraints and attitudes;
• Formation of safety review boards or committees.

CHAPTER 0 P: 0-4
0.3 ORGANIZATION AND IDENTIFICATION
0.3.1 Organization
The manual is divided into chapters. Each chapter is divided into sections. Sections may
be subdivided into one or more subsections and paragraphs, categorized by the subject or
type of information presented. Within each chapter the pages are numbered.
Example: SMS Manual, 1.10.2.2 The Meaning of Human Factors
Operations Manual Chapter Section Subsection Paragraph Title
Additions, changes or deletions are identified by a vertical line on the left hand side of the
revised page, marking the horizontal where changes or deletions occurred. Purely
redactional changes will not be marked.
0.3.2 Identification
Identification of SMS Manual is done via page headers and footers.
Header:
JC Airlines logo Number of the chapter Page [chapter-page number]
Name of the chapter Number and date of revision
Footer:
Name of the manual Airline company

CHAPTER 0 P: 0-5
0.4 TERMINOLOGY
0.4.1 Terms
When used in the SMS Manual, the following terms shall have the following meaning:
• “Shall”, “will”, “must” or an action verb in the imperative sense means that the
application of a rule or procedure or provision is mandatory.
• “Should” means that the application of a procedure or provision is recommended.
• “May” means that the application of a procedure or provision is optional.
• “No person may...” or “a person may not...” mean that no person is required,
authorised, or permitted to do the act concerned.
• “Approved” means the Authority has reviewed the method, procedure or policy in
question and issued an approval.
• “Acceptable” means the Authority or the Company has reviewed the method,
procedure or policy and has neither objected to nor approved its proposed use or
implementation.
• “Prescribed” means the Authority or the Company has issued a written policy or
methodology which imposes either a mandatory requirement, if it states “shall”,
“will”, “must” or an action verb in the imperative sense, are commended requirement
if it states “should” or a discretionary requirement if it states “may”.
• “Note” is used when an operating procedure, technique, etc., is considered
essential to be emphasised.
• “Caution” is used when an operating procedure, technique, etc., may result in
damage to equipment if not carefully followed.
• “Warning” is used when an operating procedure, technique, etc., may result in
personnel injury or loss of life if not carefully followed.
• “He/him” is used as a generic term throughout the manual, but applies equally to
operations personnel of either gender.

CHAPTER 0 P: 0-6
0.4.2 Synonyms
The following list of synonyms may be used to cross-reference the

abbreviations/words/terms used in this manual with the abbreviations/words/terms that
may be encountered in other operational and aviation documents:
• A320 - Airbus 320 - 320
• Aerodrome - Airport - Airfield
• Aircraft - Airplane - Aeroplane
• Before - Prior
• Cabin Crew - Cabin Crew Members - Flight Attendants - Cabin Attendants
• Cabin Crew in Charge - Cabin Service Manager - Senior Cabin Crew Member
• Cockpit - Flight Deck
• Commander - Captain - (Pilot-in-Command)
• Country - State
• First Officer - Co-pilot
• JC Cambodia International Airlines - JC Airlines
• Previous - Preceding
• Quantity - Amount
• Sector - Leg
• Sufficient - Adequate
• To Allow - To Permit
• Transport - Carriage

CHAPTER 0 P: 0-7
0.5 ABBREVIATIONS
The following abbreviations are used in this manual or corresponding documents:
A
A320 Airbus 320
A/C Aircraft
ADREP Accident/Incident Data Reporting (ICAO)
AEP Airport Emergency Plan
AIP Aeronautical Information Publication
AIRPROX Aircraft Proximity
ALoSP Acceptable Level of Safety Performance
AMO Approved Maintenance Organization
AOC Air Operator’s Certificate
AOG Aircraft on Ground
ALARP As Low As Reasonably Practicable
ASAP As Soon As Possible
ASPAC Asia/Pacific (IATA Region)
ASR Air Safety Report
ATA Air Transport Association
ATC Air Traffic Control
ATL Aircraft Technical Log
ATM Air Traffic Management
ATS Air Traffic Service(s)
C
CAA Civil Aviation Authority
CAN Corrective Action Notice
CAT Clear Air Turbulence
CBA Cost-Benefit Analysis
CCAR Cambodian Civil Aviation Regulations
CDL Configuration Deviation List
CEO Chief Executive Officer
CFIT Controlled Flight into Terrain
CIC Cabin Crew in Charge
CMC Crisis Management Centre
CMDR Commander
CPT Captain
CRM Crew Resource Management
CVR Cockpit Voice Recorder
D
DFDR Digital Flight Data Recorder
DGR Dangerous Goods Regulation

CHAPTER 0 P: 0-8
E
EASA European Aviation Safety Agency
EGPWS Enhanced Ground Proximity Warning System
EMER Emergency
ERC Emergency Response Centre
ERM Emergency Response Manual
ERP Emergency Response Plan
ERT Emergency Response Team
F
FAA Federal Aviation Administration
FDA Flight Data Analysis
FDM Flight Data Monitoring
FDR Flight Data Recorder
FIS Flight Information Services
FO First Officer
FOD Foreign Object Damage
FOM Flight Operations Manager
FRMS Fatigue Risk Management System
FSO Flight Safety Officer
FTL Flight Time Limitation
G
GA Go-Around
GNSS Global Navigation Satellite System
H
H Hazard
HF Human Factors
HIRA Hazard Identification and Risk Assessment
HIRM Hazard Identification and Risk Mitigation
I
IATA International Air Transport Association
ICAO International Civil Aviation Organization
IFALPA International Federation of Air Line Pilots’ Associations.
IMC Instrument Meteorological Conditions
INOP Inoperative
IOSA IATA Operational Safety Audit
ISAGO IATA Safety Audit for Ground Operations
ISO International Organization for Standardization
J
JAA Joint Aviation Authorities

CHAPTER 0 P: 0-9
L
LEP List of Effective Pages
LMT Local Mean Time
LOFT Line Oriented Flight Training
LOSA Line Operations Safety Audit
M
MEL Minimum Equipment List
MOR Mandatory Occurrence Report
MRO Maintenance Repair Organisation
N
N/A Not Applicable
NOTAM Notices to Airmen
NTSB National Transportation Safety Board (U.S.)
O
OBS Observer
OCC Operations Control Centre
OM Operations Manual
OPS Operations
OSHE Occupational Safety, Health and Environment
P
PF Pilot Flying
PM Pilot Monitoring
PPR Prior Permission Required
Q
QA Quality Assurance
QAR Quick Access Recorder
QC Quality Control
QM Quality Management
QMS Quality Management System
R
RA Resolution Advisory
ROR Record of Revision
RTO Rejected Take-Off
S
SAG Safety Action Group
SAR Search and Rescue
SARPs Standards and Recommended Practices (ICAO)
CHAPTER 0 P: 0-10
SD Standard Deviation
SHEL Software/Hardware/Environment/Liveware
SI Safety Indicator
SIL Safety Issues List
SM Safety Management
SM Safety Manager
SMS Safety Management System
SMSM Safety Management System Manual
SOP Standard Operating Procedures
SPI Safety Performance Indicator
SRB Safety Review Board
SRC Safety Review Committee
SRM Safety Risk Management
SSCA State Secretariat of Civil Aviation
SSP State Safety Programme
T
TBA To Be Announced
TBC To Be Confirmed
TBD To be Determined
TCAS Traffic Alert and Collision Avoidance System
TEM Threat and Error Management
TEMPO Temporary
U
UE Unsafe Event
U/S Unserviceable
USOAP Universal Safety Oversight Audit Programme (ICAO)
UTC Universal Time Coordinated
W
WIP Work in Progress
Z
Z Zulu (UTC)

CHAPTER 0 P: 0-11
0.6 DEFINITIONS
Acceptable Level of Safety Performance (ALoSP): The minimum level of safety

performance of civil aviation in a State, as defined in its State safety programme, or of an
airline, as defined in its safety management system, expressed in terms of safety
performance targets and safety performance indicators.
Accident Precursor: Event(s) which, without appropriate mitigation, can result in

undesirable events, incidents and accidents.
Accountable Executive: A single, identifiable person having responsibility for the effective
and efficient performance of the State’s SSP or of the service provider’s SMS.
Audit: A systematic, independent and documented process for obtaining evidence and
evaluating it objectively to determine the extent to which requirements are complied with.
Cabin Safety-related Event: Accident involving cabin operations issues, such as a

passenger evacuation, an onboard fire, a decompression or a ditching, which requires
actions by the operating cabin crew.
Change Management: A formal process to manage changes within an organization in a

systematic manner, so that changes which may impact identified hazards and risk
mitigation strategies are accounted for, before the implementation of such changes.
Commander: The pilot responsible for operation and safety of the aircraft during flight
time, used interchangeably with captain.
Company: JC Cambodia International Airlines.
Crew Member: Anyone on board a flight who has duties connected with the sector of the
flight during which the accident happened.
Defences: Specific mitigating actions, preventive controls or recovery measures put in

place to prevent the realization of a hazard or its escalation into an undesirable
consequence.
Errors: An action or inaction by an operational person that leads to deviations from

organizational or the operational person’s intentions or expectations.
Evacuation: Passengers and/or crew evacuate aircraft via escape slides, doors,
emergency exits, or gaps in fuselage, usually initiated in life threatening or catastrophic
events.
Event: In FDM system, event means any exceedance of pre-defined flight parameter
threshold, regardless of its impact on operational safety.

CHAPTER 0 P: 0-12
Evidence: A documented statement of fact, this may be quantitative or qualitative, based

on observations, measurements or tests that can be verified. Objective evidence may be
found from: document or manual review, equipment examination, activity observation or
interview data.
Exposure: Defined as the amount of time, number of events, number of people involved,
how much equipment involved, the amount of activity during which mishap exposure
exists, etc. It identifies generally how many people will be exposed to what hazards and for
how long.
Finding: A non-compliance with the applicable requirements of any specified regulation or

standard, regarding the organisation’s procedures and manuals or with the terms of an
approval or certificate.
Flight Data Monitoring: means the proactive and non-punitive use of digital flight data
from routine operations to improve aviation safety.
Fatality: A passenger or crew member who is killed or later dies of their injuries resulting
from an operational accident. Injured persons who die more than 30 days after the
accident are excluded.
Hazard: A condition, object, activity or event with the potential of causing injuries to
personnel, damage to equipment or structures, loss of material, or reduction of the ability
to perform a prescribed function.
Hazard Consequence: A potential outcome of a hazard. The damaging potential of a

hazard materializes through one or many consequences.
High-Consequence Indicators: Safety performance indicators pertaining to the

monitoring and measurement of high-consequence occurrences, such as accidents or
serious incidents. High-consequence indicators are sometimes referred to as reactive
indicators.
Hull Loss: An accident in which the aircraft is destroyed or substantially damaged and is
not subsequently repaired for whatever reason including a financial decision of the owner.
IATA Regions: IATA determines the accident region based on the operator’s home
country as specified in the operator’s Air Operator Certificate (AOC). For example, if a
Cambodian-registered operator has an accident in Europe, this accident is counted as an
“Asia/Pacific” accident.
Incident: An occurrence, other than an accident, associated with the operation of an

aircraft which affects or could affect the safety of operation.

CHAPTER 0 P: 0-13
In-flight Security Personnel: An individual, who is trained, authorized and armed by the
state and is carried on board an aircraft and whose intention is to prevent acts of unlawful
interference.
Inspection: An independent documented conformity evaluation by observation and

judgement accompanied as appropriate by measurement, testing or gauging, in order to
verify compliance with applicable requirements (incl. procedures, work instruction
standards, etc.).
Investigation: A process conducted for the purpose of accident prevention, which

includes the gathering and analysis of information, the drawing of conclusions, including
the determination of causes and, when appropriate, the making of safety
recommendations.
Investigator in Charge: A person charged, on the basis of his qualifications, with the
responsibility for the organization, conduct and control of an investigation.
Involved: Directly concerned, or designated to be concerned, with an accident or incident.
Level of Safety: How far safety is to be pursued in a given context, assessed with
reference to an acceptable risk, based on the current values of society.
Likelihood: Likelihood is used in this manual as a synonym of probability. It is a measure

of how likely something is to happen. Note: In the ICAO Doc 9859 AN/474 Safety
Management Manual, Third Edition, safety risk probability is defined as the likelihood or
frequency that a safety consequence or outcome might occur.
Lower-Consequence Indicators: Safety performance indicators pertaining to the

monitoring and measurement of lower-consequence occurrences, events or activities such
as incidents, non-conformance findings or deviations. Lower-consequence indicators are
sometimes referred to as proactive/predictive indicators.
Major Repair: A repair which, if improperly done, might appreciably affect weight, balance,
structural strength, performance, power plant operation, flight characteristics, or other
qualities affecting airworthiness.
Non-operational Accident: This definition includes acts of deliberate violence (sabotage,

war, etc.), and accidents that occur during crew training, demonstration and test flights.
Sabotage is believed to be a matter of security rather than flight safety, and crew training,
demonstration and test flying are considered to involve special risks inherent to these
types of operations. Also included in this category are accidents where there has been no
intention of flight.
Observation: An unsatisfactory condition, which could not be classified as non-

compliance.

CHAPTER 0 P: 0-14
Occurrence: Any unusual or abnormal event involving an aircraft, including but not limited
to, an incident.
Operational Accident: An accident which is believed to represent the risks of normal

commercial operation, generally accidents which occur during normal revenue operations
or positioning flights.
Operator: A person, organization or enterprise engaged in, or offering to engage in,

aircraft operations.
Passenger: Anyone on board a flight who, as far as may be determined, is not a crew
member. Apart from normal revenue passengers this includes off-duty staff members,
positioning and relief flight crew members, etc., who have no duties connected with the
sector of the flight. Security personnel are included as passengers as their duties are not
concerned with the operation of the flight.
Rapid Deplaning: Passengers and/or crew rapidly exit aircraft via boarding doors and via
jet bridge or stairs, for precautionary measures.
Risk: The assessment, expressed in terms of predicted probability and severity, of the
consequence(s) of a hazard, taking as reference the worst foreseeable situation.
Risk Mitigation: The process of incorporating defences or preventive controls to lower the
severity and/or likelihood of a hazard’s projected consequence.
Safety: The state in which the risk of harm to persons or property damage is reduced to,
and maintained at or be-low, an acceptable level through a continuing process of hazard
identification and risk management.
Safety Management System: A systematic approach to managing safety, including the

necessary organizational structures, accountabilities, policies and procedures.
Safety Performance: Safety achievement as defined by the safety performance targets

and measured by safety performance indicators.
Safety Performance Indicator: A data-based safety parameter used for monitoring and
assessing safety performance.
Safety Performance Monitoring: The process by which the Company’s safety

performance is monitored and assessed against the Company’s safety policy and safety
objectives.
Safety Risk: The predicted probability and severity of the consequences or outcomes of a
hazard.

CHAPTER 0 P: 0-15
State Safety Programme: An integrated set of regulations and activities aimed at

improving safety.
Sector: The operation of an aircraft between take‑off at one location and landing at
another (other than a diversion).
Serious Injury: An injury which is sustained by a person in an accident and which:

• Requires hospitalization for more than 48 hours, commencing within seven day
from the date the injury was received; or
• Results in a fracture of any bone (except simple fractures of fingers, toes or nose);
or
• Involves lacerations which cause severe haemorrhage, or nerve, muscle or tendon
damage;
• Involves injury to any internal organ; or
• Involves second or third-degree burns, or any burns affecting more than five
percent of the surface of the body; or
• Involves verified exposure to infectious substances or injurious radiation.
Serious Incident: An incident involving circumstances indicating that an accident nearly

occurred (note the difference between an accident and a serious incident lies only in the
result).
Sky Marshal: Refer to In-flight Security Personnel.
Substantial Damage: Damage or structural failure, which adversely affects the structural
strength, performance or flight characteristics of the aircraft, and which would normally
require major repair or replacement of the affected component.
Undesirable Event: A stage in the escalation of an accident scenario where the accident
will occur, unless an active recovery measure is available and is successfully used.
Unstable Approach: Approach where the aircraft has knowledge about vertical, lateral or
speed deviations in the portion of the flight close to landing. This definition includes the
portion immediately prior to touchdown and in this respect the definition might differ from
definition in other documents. However, accident analysis gives evidence that a
destabilization just prior to touchdown has contributed to accidents in the past.

CHAPTER 0 P: 0-16
Intentionally Blank

CHAPTER 1 P: 1-1
SAFETY POLICY AND OBJECTIVES Rev. 00, 10 JAN 2017
1 SAFETY POLICY AND OBJECTIVES

1.1 CONCEPT OF SAFETY
Safety holds the key to JC Airlines’ future and affects all its activities. The Company's
management is committed to the aviation SMS, and will give leadership to the program
and demonstrate it through everyday actions, the commitment to safety and its priority in
the achievements of the organization's safety objectives. The processes in place in the
SMS include the active involvement of all managers and supervisors, who, through
planning and review, will continue to promote efforts for continued improvement in safety
and safety performance. The term “Safety Management” should be taken to mean safety,
quality & security management.
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:
• Zero accidents (or serious incidents) - a view widely held by the travelling public;
• The freedom from danger or risks, i.e. those factors which cause or are likely to
cause harm;
• The attitude towards unsafe acts and conditions by employees (reflecting a “safe”
corporate culture);
• The degree to which the inherent risks in aviation are “acceptable”;
• The process of hazard identification and risk management; and
• The control of accidental loss (of persons and property, and damage to the
environment).
While the elimination of accidents (and serious incidents) would be desirable, a one
hundred percent 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.
Safety is increasingly viewed as the management of risk. This primary purpose of this
manual is to develop a system at JC Airlines for managing the core business process of
safety and to ensure compliance with all national and international guidelines on safety
management system.
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.

CHAPTER 1 P: 1-2
1.2 STATUTORY REQUIREMENTS
Safety has always been the overriding consideration in all aviation activities. This is
reflected in the aims and objectives of national and international regulations to ensure the
safe and orderly growth throughout the world.
ICAO differentiates between safety programs and safety management system (SMS) as
follows:
A safety program is an integrated set of regulations and activities aimed at improving

safety. ICAO’s Standard and Recommended Practices (SARPs) require that States
establish a safety program to achieve an acceptable level of safety in aviation operations.
A safety program will be broad in scope, including many safety activities aimed at fulfilling
the program’s objectives. A State’s safety program embraces those regulations and
directives for the conduct of safe operations. The safety program may include provisions
for such diverse activities as incident report, safety investigations, safety audits and safety
promotion. To implement such safety activities in an integrated manner require a coherent
Safety Management System (SMS).
Safety management system (SMS) is an organized approach to managing safety including

the necessary organized structures, accountabilities, policies and procedures. In
accordance with the provision of national regulations, The State Secretariat of Civil
Aviation (SSCA) shall require the individual operators to implement the SMS acceptable by
the state (SSCA). As a minimum, such SMS shall:
• Identify safety hazard;
• Ensure that remedial actions necessary to mitigate the risks/hazards are
implemented;
• Provide for continuous monitoring and regular assessment of the safety level
achieved;
• Aim to make continuous improvement to the overall level of safety.
An organization’s SMS shall also clearly define lines of safety accountabilities including
direct accountabilities for safety on the part of senior management.
Safety is a vital component of JC Airlines mission. Safety is also a source of competitive

advantage. All levels of line management are accountable for safety performance, starting
with the Accountable Manager, which will demonstrate continual commitment to safety by
making safety excellence an integral part of all flight and ground activities through the
policies, procedures and programs contained in this manual.
It is vital that all personnel understand that they too bear the responsibility of carrying out
their duties in the safest manner possible. Before any work is done, each personnel must
be aware of all safety rules and procedures, as well as their personal responsibility to

CHAPTER 1 P: 1-3
observe them. Safety is an extremely important part of personnel's performance and will
be recognized.
To achieve appropriate safety standards efforts must be made and implemented to

prevent injury or damage to people and property – both on the ground and in the air before
they occur.
JC Airlines requires all personnel to exercise the highest degree of care in all operations to
minimize the possibility of an accident resulting in injury or damage.
To accomplish this JC Airlines operates under the following policy:

• Direct responsibility for the safety of an operation rests with the manager of that
operation;
• Each individual is personally responsible to perform his duties giving primary
concern to his own safety as well as that of his fellow personnel, clients and the
property entrusted to their care.
Management at all levels shall provide a means for prompt corrective action to eliminate
unsafe acts, conditions, equipment or mechanical hazards.
Although the safety procedures and policies contained within JC Airlines’ SMS address the
majority of our operations, unusual situations may arise. Contact the Safety Department if
you have questions or need assistance in implementing specific standards.
JC Airlines’ SMS is composed of four functional components, including an intangible, but

always critical, aspect called safety culture:
• Safety Policy;
• Safety Risk Management;
• Safety Assurance;
• Safety Promotion.
JC Airlines’ documented SMS components and elements are in line with the SSCA’s SMS
requirements.
Safety policy establishes senior management's commitment to continually improve safety,

defines the methods, processes, and organizational structure needed to meet safety goals.
It establishes management commitment to safety performance through SMS, clear safety
objectives and commitment to manage to those objectives. Safety policy defines methods,
processes, and organizational structure needed to meet safety goals, it establishes
transparency in management of safety (fully documented policy and processes, employee
reporting and resolution system, accountability of management and employees), builds
upon the processes and procedures that already exist and facilitates cross-organizational
communication and cooperation.

CHAPTER 1 P: 1-4
Safety risk management determines the need for, and adequacy of, new or revised risk
controls based on the assessment of acceptable risk. A formal process within the SMS is
composed of describing the system, identifying the hazards, assessing the risk, analysing
the risk and controlling the risk.
Safety assurance evaluates the continued effectiveness of implemented risk control

strategies and supports the identification of new hazards. It processes SMS management
functions that systematically provide confidence that organizational outputs meet or
exceed safety requirements. Safety assurance ensures compliance with SMS
requirements and SSCA regulations, standards, policies and directives. It includes
information acquisition, audits and evaluations, employee reporting, flight data monitoring,
system assessment, etc. Safety assurance provides insight and analysis regarding
methods/opportunities for improving safety and minimizing risk. Existing safety assurance
functions will continue to evaluate and improve JC Airlines’ operations and services.
Safety promotion includes training, communication, and other actions to create a positive
safety culture within all levels of the Company. Safety promotion activities within the SMS
framework include: providing SMS training, advocating/strengthening a positive safety
culture, system and safety communication and awareness, matching competency
requirements to system requirements, disseminating safety lessons learned and
emphasising that everyone within the Company has a role in promoting safety.
The following are the main elements of JC Airlines’ safety management system:
• Safety Policy and Accountability;
• Coordinated Emergency Response Planning;
• Development, Control and Maintenance of Safety Management Documentation;
• Hazard Identification;
• Risk Management;
• Safety Investigation;
• Monitoring and Measuring Performance;
• Management of Change;
• Continual Improvement of the SMS;
• Internal Audit Programme;
• Management Review:
• Safety Training and Education Programme;
• Communication of Safety Critical Information.

CHAPTER 1 P: 1-5
1.3 SAFETY POLICY
The JC Airlines Safety Policy is a written statement signed by the Accountable Manager,
outlining Senior Management commitment to high standards of safety management as an
integral part of the airline's business processes. The safety policy is relevant to aviation
safety, scope and complexity of the JC Airlines’ operations, and is provided to all
employees within the airline for their attention and understanding:
Safety Policy Statement
Safety is one of our core business functions. We are committed to developing,

implementing, maintaining and constantly improving strategies and processes to ensure
that all our aviation activities take place under a balanced allocation of organizational
resources, aimed at achieving the highest level of safety performance and meeting
national and international standards, while delivering our services. In delivering our
company vision, JC Airlines is committed to ensuring a high level of safety in the services
we offer our customers and that our employees are provided with a safe working
environment, safe work equipment and safe methods of work.
All levels of management and all employees are accountable for the delivery of this
highest level of safety performance, starting with the top management downwards.
Our commitment is to:

• Support the management of safety through the provision of all appropriate
resources, that will result in an organizational culture that fosters safe practices,
encourages effective safety reporting and communication, and actively manages
safety with the same attention to results as the attention to the results of the other
management systems of the organization;
• Enforce the management of safety as a primary responsibility of all managers and
employees;
• Clearly define for all staff, managers and employees alike, their accountabilities and
responsibilities for the delivery of the organization’s safety performance and the
performance of our safety management system;
• Establish and operate hazard identification and risk management processes,
including a hazard reporting system, in order to eliminate or mitigate the safety risks
of the consequences of hazards resulting from our operations or activities to a point
which is as low as reasonably practicable (ALARP);
• Ensure that no action will be taken against any employee who discloses a safety
concern through the hazard reporting system, unless such disclosure indicates,
beyond any reasonable doubt, an illegal act, gross negligence, or a deliberate or
wilful disregard of regulations or procedures;
• Comply with and, wherever possible, exceed, legislative and regulatory
requirements and standards;

CHAPTER 1 P: 1-6
• Ensure that sufficient skilled and trained human resources are available to
implement safety strategies and processes;
• Ensure that all staff are provided with adequate and appropriate aviation safety
information and training, are competent in safety matters, and are allocated only
tasks commensurate with their skills;
• Establish and measure our safety performance against realistic safety performance
indicators and safety performance targets;
• Use FDM data for identifying, monitoring and mitigating safety risks (no punitive use
of FDM data will be made at the FDM programme level);
• Continually improve our safety performance through management processes that
ensure that relevant safety action is taken and is effective; and
• Ensure externally supplied systems and services to support our operations meet
our safety performance standards.
This is commonly summarised as “Safety is our Top Priority.”
________________________
Ms. Huang Dong Yan
CEO / Accountable Manager
JC Cambodia International Airlines
Senior management develops and endorses the safety policy, which is signed by the
Accountable Manager. In accordance with the safety policy, the senior management:
• Is visibly endorsing the policy;
• Is communicating the policy to all appropriate staff;
• Has established safety performance targets for the SMS and the Company;
• Has established safety objectives that identify what the Company intends to achieve
in terms of safety management.
JC Airlines safety policy includes a commitment to:

• Achieve the highest safety standards;
• Comply with all applicable regulatory requirements;
• Comply with international standards;
• Adopt proven best practices appropriate to the activity;
• Provide all the necessary resources;
• Ensure safety is a primary responsibility of all managers;
• Follow the disciplinary policy;
• Ensure that the safety policy is understood, implemented and maintained at all
levels.

CHAPTER 1 P: 1-7
In implementing a safe working environment, together with safe work equipment and safe
methods of work, JC Airlines undertakes to:
• Provide adequate control of the health and safety risks arising from Company’s
work activities;
• Consult with the employees on matters affecting their health and safety;
• Provide and maintain safe plant and equipment;
• Ensure safe handling and use of substances;
• Provide information, instruction and supervision for employees;
• Ensure all employees are competent to do their tasks, and to give them adequate
training;
• Prevent accidents and cases of work related ill health;
• Maintain safe and healthy working conditions;
• Review and amend this policy, as necessary, at regular intervals.
Conclusion to safety policy statement:

• Safety is everyone’s responsibility;
• It is integral to all work;
• Safety is the top priority in JC Airlines;
• Safety awareness and consciousness shall be all pervading and ubiquitous in what
all JC Airlines personnel do or plan;
• Top management will provide leadership in a comprehensively meaningful way to
continually promote safety performance in all aspects of Company’s business.
JC Airlines embraces the following safety principles:

• Our people are expected to operate in the safest manner practicable;
• We will foster a culture of open reporting of all occurrences and safety hazards in
which management will not initiate disciplinary action against any personnel, who in
good faith, due to unintentional conduct, disclose a hazard or safety incident;
• We will never take unnecessary risks;
• We understand that safe does not mean risk free;
• Everyone is responsible for the identification and management of risk;
• We will report all hazards we find;
• We understand that familiarity and prolonged exposure without a mishap leads to a
loss of appreciation of risk.

CHAPTER 1 P: 1-8
1.4 SAFETY OBJECTIVES AND GOALS
The primary safety objectives of JC Airlines through the Safety Management System are
the identification, elimination and/or control of hazards to a risk level defined as ALARP (as
low as reasonably practical).
The primary operations objective of JC Airlines is to conduct air transport activities safely.
The management of safety is not only the responsibility of management. It is management
that introduces the necessary procedures to ensure a positive cultural environment and
safe practices. Reporting situations, events and practices that compromise safety should
become a priority for all employees according to no-blame policy. Our policy in the
Company is to continually work to improve the standard of safety in our operations and
conform to the best operating practices of the commercial air transport industry.
The safety objectives of JC Airlines are to:

• Provide a safe environment for all JC Airlines employees, partners, suppliers and
customers. This is accomplished through the Company's safety policies;
• Ensure safety operation of all flights, without serious incidents and accidents, and to
minimize incidents that are attributable to organizational factors;
• Increase knowledge and safety awareness among all JC Airlines staff members,
and to the extent possible, among Company’s partners, suppliers and customers,
and the public generally;
• Develop a complete Safety Management System (reactive, proactive and
predictive);
• Develop a safety culture environment with JC Airlines’ own specific characteristics;
• Meet the highest safety requirements of the State safety programme;
• Increase efficiency and reduce costs.
In accordance with the safety objectives, JC Airlines identifies basic safety goals as
follows:
• To ensure safety operation of all flights, without serious incidents and accidents;
• Develop effective safety management system;
• Build up successful non-punitive reporting policy - “just culture”.
To assist the Company in fulfilling its commitment to safety, JC Airlines:

• Requires compliance with its procedures, standards and regulations at all times;
• Will provide for an occurrence reporting scheme and evaluation of incidents and
accidents;
• Will provide a form of staff communication of safety concerns and their resolution;
• Recognizes that human error will occur and that resolution of such problems takes
precedence over apportionment of blame or punitive action.

CHAPTER 1 P: 1-9
JC Airlines has established and shall maintain an accident prevention and flight safety
programme, whose primary objective will be to reduce and control the risks involved in
flight operations, ground operations, aircraft maintenance and engineering, in order to
deliver the highest levels of safety.
The primary role of the JC Airlines' Safety Department is to promote programs that support
operational excellence, prevent accidents and incidents, and manage corporate risk. The
Company Safety Management System (SMS) is proactive, predictive, and data-driven in
nature. SMS components include the collection, analysis, and dissemination of safety
information. The purpose of the SMS is to raise safety awareness throughout the
Company.
We have compiled a safety statement which details the arrangements which are in place
to safeguard the health and safety of all our people. It is fundamental that everybody in JC
Airlines reads this document carefully and understands their role in, and the overall
arrangement for health and safety in our airline. A copy of this statement is available at
least at the following locations:
• Accountable Manager (Chief Executive Officer) Office;
• Safety Manager Office;
• Operations Control Center;
• Quality Department;
• Flight Operations Department;
• Ground Operations Department;
• Training Department;
• Engineering & Maintenance Department;
and is also sent by e-mail to all employees.
The safety policy shall be periodically reviewed to ensure it remains relevant and
appropriate to the organisation. Safety Manager shall propose revision of safety statement
to Accountable Manager. Accountable Manager approves proposal by signature.
Our prime responsibility as airline employees is to do everything in our power to ensure

that accidents and incidents are avoided. Therefore the success of our safety policy
depends on each other and everyone of us working together to continually improve safety.
Safety policy and objectives consist of five basic elements:

• Management commitment and responsibility;
• Safety accountabilities of managers;
• Appointment of key safety personnel;

CHAPTER 1 P: 1-10
• Emergency response plan;

• Documentation.
The disciplinary policy is used to determine whether a violation has occurred requiring
action beyond the analysis requirements of the risk management systems. Therefore, it is
essential to assure that persons responsible for making that determination have the
necessary technical expertise to fully consider the context related to the report, thereby
diminishing the likelihood that such personnel and the Company may be exposed to unfair
or inappropriate “disciplinary/judicial” proceedings. One approach to be used in making
this determination is James Reason’s unsafe acts algorithm to help front-line managers
determine the accountability of person(s) involved in an incident. Refer to figure below:
As the reference for standard or below standard SMS performance and implications, the
following is considered as SMS standard performance level:
• Performed investigations on all Safety Reports;
• All proposed mitigation measures processed in timely manner;
• All required corrective actions processed in timely manner;
• 4 meetings of each Safety Action Group per year,
• 1 SMS Bulletin issued yearly.
Evaluation of SMS performance is performed yearly within the Safety Review Board.

CHAPTER 1 P: 1-11
1.5 JC AIRLINES’ SAFETY CULTURE
The following is the description of safety culture in JC Airlines:

• All employees of JC Airlines have the right to say and do about safety concern in
accordance with their functions and responsibilities. JC Airlines encourages
participations of all individuals in Company’s safety management process;
• JC Airlines personnel at all levels have responsibilities to understand and actively
participate in Company’s safety management process;
• CEO, Accountable Manager and nominated post holders (managers of
departments, as appropriate) take a leading role in developing an active safety
culture within JC Airlines organisation. Commitments of leading management are
standard basis of JC Airlines’ safety culture;
• JC Airlines managers are responsible for creating a reliable working environment,
through setting a good example in implementation of commitments;
• Two-way public information between senior management and all staff member
through non-punitive reporting policy (Just Culture) is encouraged. All employees
will be trained on safety issues and safety culture. Sufficient resources will be
provided to address related safety issues in the Company;
• All members of JC Airlines are responsible for thorough understanding of safety
culture of the Company. Each member shall be aware of his individual role in the
Company's safety management processes, maintaining the air safety and providing
safety reports and recommending safety solutions for Company’s operation.
Non-Punitive Reporting Policy - Just Culture is one of the basic elements of Safety
Culture. Purpose of JC Airlines’ non-punitive reporting policy is to:
• Implement commitments of JC Airlines management to develop JC Airlines’ Just
Culture;
• Protect safety information sources;
• Encourage all staff (including staff of JC Airlines service providers) in reporting all
safety concerns to the attention of management.
JC Airlines cultivates and fosters a generative safety culture in which employees and
customers are comfortable and encouraged to bring safety concerns to the attention of
management. JC Airlines is committed that no person will be penalized or retaliated
against for bringing safety issues to the attention of Safety Department. To ensure this
commitment, we have uninhibited reporting of all incidents and occurrences that
compromise the safety of our operations.
JC Airlines asks each employee to accept the responsibility to communicate any

information that may affect the integrity of flight safety. Employees must be assured that
this communication will never result in reprisal, thus allowing a timely, uninhibited flow of
information to occur.

CHAPTER 1 P: 1-12
All employees are advised that JC Airlines will not initiate disciplinary action against an
employee who discloses an incident or occurrence involving flight safety. However, this
policy cannot apply to criminal, international or regulatory infractions.
JC Airlines has developed safety reporting system to be used by all employees for
reporting information concerning flight safety. They are designed to protect the identity of
the employee who provides information. Certain report forms are readily available in
employee work areas.
All employees are urged to help JC Airlines continue its leadership in providing its
customers and employees with the highest level of flight safety.

CHAPTER 1 P: 1-13
1.6 APPOINTMENT OF KEY SAFETY PERSONNEL
JC Airlines maintains its standards through the support of the Safety Department. This
requires that the staff is involved in developing the standards, responsibilities are made
clear, and all staff consistently work to the standards. JC Airlines has a policy that requires
personnel performing satiety related work to be physically and mentally fit for duty.
JC Airlines appoints a Safety Manager who is responsible for the implementation and
maintenance of an effective SMS. The safety manager is supported by additional staff
(Flight Safety Officer, specialist(s), as appropriate).
The ultimate responsibility for safety rests with the management of JC Airlines. The
Company's attitude to safety is established from the outset by the extent which senior
management accepts responsibility for safe operations, particularly the proactive
management of risk.
All department managers within JC Airlines are responsible according to Safety

Management Systems (SMS) to deliver required information to Safety Manager
immediately. However, without the wholehearted commitment of all personnel, any safety
program is unlikely to be effective.
There will always be hazards, both real and potential, associated with the operation of any
aircraft. Technical operational and human failures induce the hazards. The aim of every
safety program therefore is to address and control them. This is achieved through the
establishment of a safety program which ensures the careful recording and monitoring of
safety-related occurrences for adverse trends in order to prevent the recurrence of similar
incidents which could lead to an aircraft accident. It is best accomplished by the Safety
Manager whose responsibility is to promote safety awareness and to ensure that the
prevention of aircraft accidents is the priority throughout all Company departments.

CHAPTER 1 P: 1-14
1.7 SAFETY RESPONSIBILITIES AND ACCOUNTABILITIES

1.7.1 Management Responsibilities
JC Airlines management is responsible for ensuring that all Company personnel have a
safe and healthful work environment, operations are conducted safely, and compliance
with regulatory requirements is maintained.
All JC Airlines managers are individually responsible that operations are conducted in a
safe and efficient manner, protecting the personnel and equipment.
All managers are responsible for, and have a legal obligation to ensure, a safe and
healthful workplace free from recognized hazards that may cause serious injury or illness.
Taking reasonable actions to protect people, property and the environment discharges this
responsibility.
Some specific responsibilities are:

• Ensuring State, and Company safety and health standards are followed;
• Monitoring contracted services’ personnel for compliance;
• Ensuring accident/incident, damages, and injuries are promptly reported and
investigated;
• Ensuring a copy of JC Airlines SMS Manual is made available for employee’s use
and reference at each work location;
• Inspecting workplaces on a regular basis to identify potential safety hazards and
taking effective corrective actions to permanently eliminate hazards;
• Providing staff safety training;
• Enforcing safety rules and procedures;
• Ensuring protective equipment is available and used by everyone;
• Providing the necessary tools, equipment, and facilities to perform work tasks
safely.
All personnel must be familiar with not only the safety policies and programs in this
manual, but also those found in JC Airlines general operations manuals and all other
manuals applicable to an employee’s given job function. The safety policies and programs
for each department of JC Airlines will be disseminated to employees during initial and
recurrent training classes provided by the applicable departments.
By adhering to established rules and procedures, each employee, from the Accountable
Manager to the front line, can help collectively achieve JC Airlines goal of maintaining a
maximum level of safety.
Management’s commitment to safety is fundamental and must be readily visible at all

levels. Every opportunity for actively demonstrating this commitment to safety must be
taken. It is the responsibility of each operating department head, and each JC Airlines
employee, to correct or prevent safety non-conformities.
CHAPTER 1 P: 1-15
To support this objective each department shall have a program to ensure action is taken
to correct and prevent safety non-conformities and that corrective and preventative action
shall be appropriated to the effects and causes of non-conformities/potential non-
conformities.
Organisational Structure of JC Cambodia International Airlines
1.7.2 Safety Department Organisation
The Safety Department is managed by the Safety Manager who reports directly to the
Accountable Manager.
Note: In JC Airlines the roles of the Safety Manager and Security Manager have been
merged in the role of Safety & Security Manager.
The Safety Department includes a Flight Safety Officer and, as applicable, specialist(s) of
internal evaluations and emergency response.
JC Airlines will allocate appropriate resources to adequately staff and equip the Safety
Department. As operational activities, such as routes and fleet size change, these
resources will be supplied as needed.

CHAPTER 1 P: 1-16
To assist the Safety Manager, the Accountable Manager may assign additional personnel
to the safety department, either as full-time or as an additional duty to other function(s).
When such appointments are made, these employees will report to the Safety Manager.
Safety Department personnel assist Safety Manager in all his duties and are responsible
for providing guidance arid direction for the planning, implementation and operation of the
Company’s Safety Management System (SMS). They have to be adequately trained by
means of completing ICAO, IATA or any other relevant Company safety courses.
Safety Department Organisation Chart and access to Accountable Manager
Safety Department is a consultative body and act as a repository for safety related reports
arid information as well as provide risk assessment and data analysis expertise to the
functional managers. Safety Department may provide data directly to the Accountable
Manager regarding major safety issues identified by the system. The responsibility for
informing the Accountable Manager of major safety deficiencies identified within their
responsible area remains with the appropriate post holder or head of organisational unit.
Furthermore, the Safety Department may be involved in discussions regarding possible
corrective action, it is the responsibility of post holder to determine what the corrective
action will be and to ensure the outcome is monitored arid evaluated. The Safety
Department does not have the authority to overturn operational decisions related to safety
issues identified by the system or the safety management system itself.
The primary role of the JC Airlines' Safety Department is to promote programs that support
operational excellence, prevent accidents and incidents, and manage corporate risk. The
Company Safety Management System (SMS) is proactive, predictive,

CHAPTER 1 P: 1-17
and data-driven in nature. SMS components include the collection, analysis, and
dissemination of safety information. The purpose of the SMS is to raise safety awareness
throughout the Company.
Note: In JC Airlines the functions of the Safety Department and Security Department
have been merged in the combined Safety & Security Department, managed by
the Safety & Security Manager.
1.7.3 Accountable Manager
The Accountable Manager is accountable for safe management of the Company and the
services provided. In discharging this safety accountability, the Accountable Manager is
responsible for:
• Defining and authorizing a safety policy that indicates JC Airlines’ safety objectives
and its commitment to safety;
• Ensuring a Safety Management System is implemented at JC Airlines;
• Assuming the leadership role to ensure commitment throughout the Company,
particularly at senior management level, to the safety management policy intent and
safety management system requirements;
• Providing appropriate and adequate resources (personnel, funding and support)
necessary to fulfil SMS requirements;
• Ensuring that JC Airlines executives and staff are aware and held accountability for
their safety performance;
• Ensuring that JC Airlines’ safety management system and operation performance
are evaluated for effectiveness on a regular basis;
• Having final authority over all aviation activities and safety issues of JC Airlines.
1.7.4 Safety Manager
The appointment of a qualified Safety Manager is key to the effective implementation and
functioning of a safety services office. There are few individuals who readily possess all
the skills are qualitative necessary to fulfil this position. The suggested minimum attributes
and qualification required are:
• A sound knowledge of operations procedures;
• A broad aviation / technical education;
• Relevant operational and safety experience;
• Formal training in risk management;
• Sound knowledge of safety management principles and practices;
• Good written and verbal communication skills;
• Well developed interpersonal skills;
• Leadership and an authoritative approach;
• Good analytical skills;
CHAPTER 1 P: 1-18
• Computer literacy;
• Organizational ability;
• Capability of working unsupervised;
• Ability to relate to all levels, both inside and outside the organization;
• Worthy of respect among peers and management.
The Safety Manager is accountable to the Accountable Manager for:

• Providing advice and assurance relating to safety issues and performance, internal,
external and international safety initiatives and requirements;
• Maintenance of the safety policy and safety management system;
• Establishing safety standards;
• Establishing a system for the safety management education and safety awareness;
• Effective interface with the SSCA regarding safety matters;
• Establishing industry liaison on safety matters;
• Establishing safety relations with international bodies;
• Disseminating public communications on safety issues;
• Organizing emergency response planning.
In discharging these accountabilities, the Safety Manager is responsible for:

• Developing and maintaining a safety management policy;
• Establishing and maintaining a safety management system including arrangements
for identifying, reporting, tracking and correcting safety issues and for the initiations
of preventive action where necessary;
• The day-to-day operation of Safety Management System;
• Periodic reviewing of the SMS policy and requirements, to ensure they remain
relevant and appropriate, as well as the deployment of the safety and quality policy
throughout the Company;
• Maintaining, reviewing and revising the Safety Management Program;
• Maintaining an appropriate reporting system to identify hazards;
• Undertaking ongoing review of the safety management system to evaluate its
effectiveness and ensuring that improvements are made where required;
• Overseeing the performance of the Company’s safety management activities and
providing advice on potential improvements to safety performance;
• Reviewing and reporting on compliance with safety management policies, plans,
systems and procedures, ensuring safety issues are reported in a timely manner.
• Overseeing hazard identification systems, for example:
– Occurrence investigations;
– Incident reporting systems;
– Data analysis programs;

CHAPTER 1 P: 1-19
• The management of safety risks in maintenance operations (ensuring that

maintenance operations are conducted in accordance with conditions and
restrictions of the Air Operator Certificate (AOC), and in compliance with applicable
regulations and standards of the JC Airlines);
• Investigating incidents and accidents;
• Encouraging a positive safety culture by providing feedback to managers and staff
about ongoing safety issues;
• Revising the Emergency Response Plan as circumstances change;
• Enhancing safety culture among all employees using all available safety recourses
such as bulletins, circulars, posters and direct contact with personnel involved;
• Planning and controlling the flight safety budget;
• Selecting the most appropriate risk mitigation measures for those risks deemed
unacceptable;
• Monitoring safety concerns in the aviation industry and their perceived impact on
the Company’s operations aimed at service delivery;
• Coordinating and communicating (on behalf of the Accountable Manager) with the
State’s oversight authority and other State agencies as necessary on issues relating
to safety;
• In coordination with Training Manager continually updating safety training in
response to current safety issues;
• Maintaining records and safety documentation;
• Coordinating safety committees/boards;
• Ensuring management continuity is maintained, during a period of his absence, due
to sickness, leave, training or for any other reason, by delegating his duties &
responsibilities (in writing) to another competent person.
The Safety Manager is the person responsible for the collection and analysis of safety data
and the distribution of related safety information to other Company's managers. The
distribution of safety information by the Safety Department is the first step in the safety risk
management process. This information must be used by Company managers to mitigate
safety risks, which inevitably requires the allocation of resources. The necessary
resources should be readily available to the managers for this purpose.
Safety Manager acts independently from other parts of the Company and should be
responsible for providing information and advice to the Accountable Manager on all
matters of safety of aircraft. Safety Manager shall be free to report urgent safety matters
directly to Accountable Manager at any time. Safety Manager shall not hold other
responsibilities that may conflict or impair his role as a person who is administering SMS.
His position within the management may not be lower than or subservient to other
operational or production positions.

CHAPTER 1 P: 1-20
Safety Manager data flow:
As day to day responsibility for safety has been delegated by the Accountable Manager
to Flight Operations Manager, Ground Operations Manager, Chief Pilot and
Maintenance Manager, the Safety Manager must work intimately with these
managers on all safety issues.

CHAPTER 1 P: 1-21
Safety Manager should ensure that JC Airlines’ SMS is coordinated or integrated with
external customer or subcontractor organizations where applicable.
Any item which is considered by the Safety Manager to be of a nature that it is critical to
the safety of flight operations, shall be immediately disseminated to all flight crew by
Safety Manager, or a person assigned by the Safety Manager to act in his absence. This
should be done by email to all concerned individuals and departments, and placed on
Company notice boards.
With the approval of JC Airlines Accountable Manager, a Deputy Safety Manager may be
nominated to assume the duties and responsibilities of Safety Manager while he is absent
from work place to ensure the continuity of work.
1.7.5 Flight Safety Officer
The Flight Safety Officer participates and supervises implementation of safety standards
and is responsible to the Safety Manager for:
• Maintaining the air safety occurrence reporting database;
• Monitoring and evaluating the Flight Data Monitoring reports and propose corrective
actions to the Safety Manager;
• Monitoring corrective actions and flight safety trends;
• Publishing, together with Safety Manager, the results of safety reviews,
investigations, surveys, audits, etc.;
• Participating in the Company Safety Review Board;
• Assisting with the investigation of accidents and conducting and coordinating
investigations into incidents;
• Participating in management strategic planning, as appropriate;
• Proposing to the Safety Manager adoption of actions in relation to improvement of
the SMS;
• Conducting other duties as anticipated by the SMS.
1.7.6 Safety Review Committee
The Safety Review Committee (SRC) (may be referred also as Safety Review Board
(SRB)) is a committee that considers strategic safety functions. Safety Review Committee
is the highest-level committee for safety monitoring. The SRC deals with macro level
issues in relation to safety policies, resource allocation and safety performance monitoring.
The board meets at least once every 6 months, unless exceptional circumstances dictate
otherwise. The Safety Manager participates in the SRC in an advisory capacity only.

CHAPTER 1 P: 1-22
The SRC ensures that appropriate resources are allocated to achieve the established
safety performance of the Company and provide strategic direction to the Safety Action
Groups (SAG).
Composition:
• Chairman: Accountable Manager;
• Advisor: Safety Manager;
• SRC’s members: Post holders of departments in the area of Flight Operations,
Ground Operations, Engineering & Maintenance and Quality Assurance, Cabin
Crew Manager, Flight Safety Officer.
The Safety Review Committee (SRC):

• Monitors and ensures that any necessary corrective/preventive action is taken in a
timely manner;
• Monitors the effectiveness of approved SMS implementation plan;
• Reviews the SMS and its safety performance;
• Monitors safety performance in accordance with JC Airlines safety policy and
objectives;
• Monitors the effectiveness of safety management processes which support the
declared corporate priority of safety management as another core business
process;
• Monitors the effectiveness of the safety supervision of subcontracted operations;
• Ensures that appropriate resources are allocated to achieve safety objectives and
safety performance indicators;
• Gives strategic direction to the SAG.
1.7.7 Safety Action Group
Safety Action Groups - SAGs – are tactical groups established to implement safety
activities synchronously in accordance with safety objectives and safety management
strategies of JC Airlines. They report to and take strategic directions from the Safety
Review Committee (SRC). Safety Manager gives necessary administrative support to
SAGs and acts as moderator on SAGs meetings, if needed and/or required.
Measurable criteria are reviewed every 3 month at a departmental level in the Safety
Action Groups (SAG).
Safety Action Groups (SAGs) are established on base of functional areas:

• Flight Operations SAG chaired by Flight Operations Manager, covering area of
Flight Operations & Crew Training;
• Ground Operations SAG chaired by Ground Operations Manager covering area of
Ground Operations;
CHAPTER 1 P: 1-23
• Technical & Maintenance SAG, chaired by Engineering & Maintenance Manager.
The Safety Action Group (SAG):

• Oversees operational safety performance and ensures that hazard identification
and safety risk management are carried out as appropriate, with staff involvement
as necessary to build up safety awareness;
• Coordinates the resolution of mitigation strategies for the identified consequences
of hazards and ensures that satisfactory arrangements exist for safety data capture
and employee feedback;
• Assesses the impact of operational changes on safety;
• Coordinates the implementation of corrective action plans and convenes meetings
or briefings as necessary to ensure that ample opportunities are available for all
employees to participate fully in management for safety;
• Ensures that corrective action is taken in a timely manner;
• Reviews the effectiveness of previous safety recommendations;
• Oversees safety promotion and ensures that appropriate safety, emergency and
technical training of personnel is carried out that meets or exceeds minimum
regulatory requirements.
A safety (SMS) coordinator should be appointed within each Safety Action Group.
1.7.8 All Personnel
All employees must perform all assigned duties with safety in mind. Each employee is
responsible and personally accountable for:
• Performing only those technical functions for which they are trained;
• Observing and following established safety and health policies, practices,
procedures and operational requirements;
• Notifying management of unsafe conditions directly or through anonymous
procedures;
• Operating only that equipment on which they have been trained and are qualified to
operate;
• Using required personal protective equipment as applicable;
• Availing themselves of safety and health training;
• Keeping work areas free of recognized hazards;
• Reporting injuries, illnesses, damage, incidents, and accidents in accordance with
JC Airlines’ policy and procedure.
Every employee is expected to accept responsibility and accountability for their actions.
Each will have an opportunity to participate in developing safety standards and procedures
by communicating their safety concerns and suggestions to the management. All must

CHAPTER 1 P: 1-24
demonstrate concern for the safety of passengers and for others in the JC Airlines
organisation.
All personnel must be familiar with not only the safety policies and programs in this
manual, but also those found in the JC Airlines general operations manual and all other
manuals applicable to an employee’s given job function. The safety policies and programs
for each department of JC Airlines will be disseminated to employees during initial and
recurrent training classes provided by the applicable departments. By adhering to
established rules and procedures, each employee, from the Chief Executive Officer and
Accountable Manager to the front line, can help collectively achieve JC Airlines’ goal of
maintaining a maximum level of safety.
All personnel performing safety related work are required to be mentally, as well as
physically, fit for duty. Those personnel that do not meet this requirement will immediately
cease those duties and notify their supervisor. Supervisors that are aware of, or made
aware of, an employee performing safety related work that is not mentally, as well as
physically, fit for duty, will immediately have that employee cease those duties.

CHAPTER 1 P: 1-25
1.8 EMERGENCY RESPONSE PLAN
1.8.1 General
JC Airlines’ Emergency Response Plan addresses all possible or likely emergency/crisis

scenarios relating to the JC Airlines’ operations. For details about Emergency Response
Plan, the authorized personnel may refer to Company’s Emergency Response Manual
(ERM).
1.8.2 The Coordination of the Emergency Response Plan
JC Airlines believes that effective emergency response planning provides an opportunity to

learn, as well as to apply, safety lessons aimed at minimizing damage or injury.
To be able to respond successfully to an emergency, it is necessary to start with effective

planning. The Emergency Response Plan and proper planning provide the basis for a
systematic approach to managing JC Airlines affairs in the aftermath of a significant
unplanned event or in the worst case, a major accident.
The Emergency Response Plan is the integral part of SMS to ensure that there is:
• Orderly and efficient transition from normal to emergency operations;
• Delegation of emergency authority;
• Assignment of emergency responsibilities;
• Authorization by key personnel for actions contained in the plan;
• Coordination of efforts to cope with the emergency;
• Safe continuation of operations or return to normal operations as soon as possible.
Measuring the effectiveness of the ERP, it should:

• Be relevant and useful to the people who are likely to be on duty at the time of an
accident;
• Include checklists and quick reference contact details of relevant personnel;
• Be regularly tested through exercises;
• Be updated when changes occur.
JC Airlines shall ensure that an Emergency Response Plan is properly coordinated with
the emergency response plans of those organisations it must interface with during the
provision of its services. Emergency Response Plan includes procedures for the
continuing safe operations during emergencies/contingencies - for details refer to
applicable chapters of ERM. JC Airlines shall distribute and communicate the ERP to all
relevant personnel, including relevant external organizations. This is the responsibility of
Emergency Director - refer to ERM.

CHAPTER 1 P: 1-26
1.8.3 ERP Contents
JC Airlines Emergency Response Plan (ERP) is documented in a separate manual

(Emergency Response Manual – ERM) and it sets out the responsibilities, roles and
actions for the various agencies and personnel involved in dealing with emergencies. The
ERP shall contain the following items:
Governing Policies - the ERP should provide direction for responding to emergencies, for
example, governing laws and regulations for investigations, agreements with local
authorities, and company policies and priorities.
Organization - the ERP should outline management’s intentions with respect to the
respond of JC Airlines by:
• Designating who will be assigned to the Emergency Response Team and specifying
who will be the leader(s);
• Defining the roles and responsibilities for personnel assigned to the Emergency
Response Team;
• Clarifying the reporting lines of authority;
• Providing instructions for the setting up of a Emergency Response Centre (Crisis
Management Centre);
• Establishing procedures for receiving a large number of requests for information,
especially during the first few days after a major accident;
• Designating the corporate spokesperson for dealing with the media;
• Defining what resources will be available, including financial authorities for
immediate activities;
• Designating the Company representative with respect to any formal investigations
undertaken by State officials;
• Defining a call-out plan for key personnel (an organization chart or flow chart could
be used to show organizational functions and communication relationships).
Notifications - the ERP specifies who in JC Airlines should be notified of an emergency,

and who will make external notifications and by what means. The notification needs of
those listed below should be considered:
• Management;
• State authorities (search and rescue, regulatory authority, accident investigation
board, etc);
• Local emergency response services (airport authorities, fire fighters, police,
ambulance services, medical agencies, etc);
• Relatives of victims (a sensitive issue that is handled by the police in many States);
• Company personnel;
• The media representatives;
• Legal, accounting and insurance representatives.
CHAPTER 1 P: 1-27
Initial Response - depending on the circumstances, an initial response team may be

dispatched to the accident site to augment local resources and oversee the organization’s
interests. Some factors to be considered for an initial response team are listed below:
• Who should lead the initial response team?
• Who should be included on the initial response team?
• Who should speak for the organization at the accident site?
• What would be required with respect to special equipment, clothing, documentation,
transportation, accommodation, etc.?
Additional Assistance - employees with appropriate training and experience can provide
useful support during the preparation, exercising and updating of an organization’s ERP.
Their expertise may be useful in planning and executing such tasks as:
• Acting as passengers in crash exercises;
• Assisting survivors;
• Dealing with next of kin.
Emergency Response Centre (Crisis Management Centre) - has been established at the
JC Airlines Company headquarters once the activation criteria have been met. In addition,
a command post may be established at or near the accident site. The ERP addresses how
the following requirements are to be met:
• Staffing;
• Communications equipment (telephones, fax, Internet, etc.);
• Maintenance of emergency activity logs;
• Impounding of company records that are relevant to the emergency;
• Office furnishings and supplies;
• Reference documents (such as emergency response checklists and procedures,
company manuals, AEPs and telephone lists).
Records - JC Airlines needs to maintain logs of events and activities as they will have to
be provided to a State investigation team. The ERP will allow for the following types of
information to be available to investigators:
• All relevant records on the aircraft, the flight crew, the operation, etc.
• Lists of points of contact and any personnel associated with the occurrence;
• Notes of interviews with, and statements by, anyone associated with the event;
• Photographic or other evidence.
ERP Training and Review - a detailed instructions and explanation regarding planning and
recording of ERP trainings, drills and exercises.
Accident Site - after a major accident, representatives from many jurisdictions have
legitimate reasons for accessing the site, for example, police, fire fighters, medics, airport
CHAPTER 1 P: 1-28
authorities, coroners, State accident investigators, relief agencies (e.g. Red Cross) and the
media. Although coordination of the activities of these stakeholders is the responsibility of
the State’s police and/or investigating authority, the JC Airlines will clarify the following
aspects of activity at the accident site:
• Nomination of a senior company representative at the accident site (wherever the
accident occurs);
• Management of surviving passengers;
• Responding to the needs of the victims’ relatives;
• Provision of security of wreckage;
• Handling of human remains and personal property of the deceased;
• Preservation of evidence;
• Provision of assistance (as required) to the investigation authorities;
• Removal and disposal of wreckage.
Crisis Communication - clear instructions will be available with respect to such matters as:
• What information is protected by statute (Flight Data Recorder (FDR) data, Cockpit
Voice Recorder (CVR) and ATC recordings, witness statements, etc.)?
• Who may speak on behalf of the parent organization at head office and at the
accident site?
• Direction regarding a prepared statement for immediate response to media queries;
• What information may or may not be released?
• The timing and content of the company’s initial statement;
• Provisions for regular updates to the media;
Formal Investigations - guidance for company personnel dealing with State accident
investigators and police should be provided in the ERP;
Family Assistance - the ERP should also include guidance on the organization’s approach
to assisting the families of accident victims (crew and passengers). This guidance may
cover such matters as:
• State requirements for the provision of family assistance services;
• Travel and accommodation arrangements to visit the accident location and
survivors;
• Provision of up-to-date information;
• Grief counselling;
• Immediate financial assistance to victims and their families; and
• Memorial services.
Post-Critical Incident Stress Counselling - the ERP should provide guidance for personnel
working in stressful situations. This may include specifying duty limits and providing for
post-critical incident stress counselling.
CHAPTER 1 P: 1-29
Post-occurrence review - direction should be provided to ensure that following the

emergency key personnel carry out a full debriefing and record all significant lessons
learned. This may result in amendments being made to the ERP and associated
checklists.
1.8.4 Aircraft Operator’s Responsibilities
JC Airlines ERP should be coordinated with the aerodrome (and other organizations, as
applicable) Emergency Response Plan so that JC Airlines personnel know what
responsibilities the airport will assume and what response is required by JC Airlines.
JC Airlines, in conjunction with the airport operator, is expected to:

• Provide training to prepare personnel for emergencies;
• Make arrangements to handle incoming telephone queries concerning the
emergency;
• Designate a suitable holding area for uninjured passengers;
• Provide a description of duties for Company personnel (e.g. person in command,
persons receiving passengers in holding areas, etc.);
• Gather essential information on passengers and coordinate fulfilment of their needs;
• Develop arrangements with other operators and agencies for the provision of
mutual support during the emergency;
• Prepare and maintain an emergency kit containing necessary administrative
supplies (forms, paper, name tags, computers, etc) and critical telephone numbers
(of doctors, local hotels, linguists, caterers, airline transport, companies, etc).
In the event of an aircraft accident at or near the airport, JC Airlines will be expected to
take certain actions, for example:
• Report to airport command post to coordinate JC Airlines activities;
• Assist in the location and recovery of any flight recorders;
• Assist investigators with the identification of aircraft components and ensure that
hazardous components are made safe;
• Provide information regarding passengers, flight crew and the existence of any
dangerous goods on board;
• Transport uninjured persons to the designated holding area;
• Make arrangements for any uninjured persons who may intend to continue their
journey or who need accommodation or other assistance;
• Release information to the media in coordination with the airport public information
officer and police;
• Remove the aircraft and/or wreckage upon the authorization of the investigation
authority.

CHAPTER 1 P: 1-30
Although the information in this paragraph is oriented towards an aircraft accident, some of
the concepts also apply to emergency response planning by aerodrome operators and
ATS providers.
JC Airlines’ ERP shall be periodically reviewed by the responsible Company personnel to

ensure its continuing relevance and effectiveness - refer to ERM.
1.8.5 Checklists
Everyone involved in the initial response to a major aircraft accident will experience some
degree of shock. Therefore, the emergency response process lends itself to the use of
checklists. These checklists can form an integral part of JC Airlines Emergency Response
Plan. To be effective, checklists must be regularly:
• Reviewed and updated (for example, call-out lists and contact details); and
• Tested through realistic exercises.
1.8.6 Training and Exercises
The ERP is a written indication of intent. Hopefully, much of an ERP will never be tested
under actual conditions.
Training is required to ensure that the intentions in the ERP are backed by operational
capabilities. Since training has a short “shelf life”, regular drills and exercises are
advisable. Some portions of the ERP, such as the call-out and communications plans, can
be tested by “desktop” exercises. Other aspects, such as “on-site” activities involving other
agencies, need to be practiced at regular intervals.
Conducting exercises has the advantage of demonstrating deficiencies in the plan, which
can be rectified before an actual emergency occurs. For details about the ERF training and
exercises refer to ERM.

CHAPTER 1 P: 1-31
1.9 SMS DOCUMENTATION

1.9.1 General
SMS documentation includes and makes reference to, as appropriate, all relevant and
applicable national and international regulations. It includes SMS-specific records and
documentation, such as hazard reporting forms, lines of accountability, responsibility and
authority regarding the management of operational safety, and the structure of the safety
management organisation. The most important piece of documentation of an SMS is the
Safety Management System manual (SMS manual). SMS manual is a key instrument for
communicating the organisation's approach to safety to the whole organisation. It
documents all aspects of the SMS, including the safety policy, objectives, procedures and
individual safely accountabilities.
Another aspect of SMS documentation is the compilation and maintenance of records

substantiating the existence and ongoing operation of the SMS. Such records should be
organized according to the respective SMS elements and associated processes.
SMS documentation shall be developed and maintained to describe:

• The safety policy and objectives;
• The SMS requirements;
• The SMS processes and procedures;
• The accountabilities, responsibilities and authorities for processes and procedures;
• The SMS outputs.
Up to date documentation is essential for JC Airlines to operate in a safe and efficient

manner in accordance with current safety regulations and standards.
The Company keeps an SMS records ensuring the retention of all records generated in
conjunction with the implementation and operation of the SMS. Records to be kept include
hazard reports, risk assessment reports, safety action group/safety meeting notes, safety
performance indicator charts, SMS audit reports and SMS training records. Records
should be traceable for all elements of the SMS and be accessible for routine
administration of the SMS as well as internal and external audits purposes.
JC Airlines has put in place procedures for periodic review of the SMS policy, procedures,
processes and supporting documentation to ensure their continuing relevance.

CHAPTER 1 P: 1-32
1.10 UNDERSTANDING SAFETY

1.10.1 Accident Causation
The Swiss-Cheese Model, developed by Professor James Reason, illustrates that

accidents involve successive breaches of multiple system defences. These breaches can
be triggered by a number of enabling factors such as equipment failures or operational
errors. Since the Swiss-Cheese Model contends that complex systems such as aviation
are extremely well defended by layers of defences, single-point failures are rarely
consequential in such systems. Breaches in safety defences can be a delayed
consequence of decisions made at the highest levels of the system, which may remain
dormant until their effects or damaging potential are activated by specific operational
circumstances. Under such specific circumstances, human failures or active failures at the
operational level act to breach the system’s inherent safety defences. The Reason Model
proposes that all accidents include a combination of both active and latent conditions.
Active failures are actions or inactions, including errors and violations, which have an
immediate adverse effect. They are generally viewed, with the benefit of hindsight, as
unsafe acts. Active failures are generally associated with front-line personnel (pilots, air
traffic controllers, aircraft mechanical engineers, etc.) and may result in a harmful
outcome.
Latent conditions are those that exist in the aviation system well before a damaging
outcome is experienced. The consequences of latent conditions may remain dormant for a
long time. Initially, these latent conditions are not perceived as harmful, but will become
evident once the system’s defences have been breached. These conditions are generally
created by people far removed in time and space from the event. Latent conditions in the
system may include those created by a lack of safety culture; poor equipment or
procedural design; conflicting organizational goals; defective organizational systems or
management decisions. The perspective underlying the organizational accident aims to
identify and mitigate these latent conditions on a system-wide basis, rather than through
localized efforts to minimize active failures by individuals.
Figure on the next page shows how the Swiss-Cheese Model assists in understanding the
interplay of organizational and managerial factors in accident causation. It illustrates that
various defences are built into the aviation system to protect against fluctuations in human
performance or decisions at all levels of the system. While these defences act to protect
against the safety risks, breaches that penetrate all defensive barriers may potentially
result in a catastrophic situation. Additionally, Reason’s Model represents how latent
conditions are ever present within the system prior to the accident and can manifest
through local triggering factors.

CHAPTER 1 P: 1-33
The concept of accident causation
1.10.2 Human Factors

1.10.2.1 Introduction
Flight safety is the main objective of JC Airlines. A major contributor to achieve that
objective is a better understanding of Human Factors and the broad application of its
knowledge. Increasing awareness of Human Factors in JC Airlines will result in a safer and
more efficient working environment.
The purpose of this section is to introduce this subject and to provide guidelines for
improving human performance through a better understanding of the factors affecting it
through the application of Crew Resource Management (CRM) concepts in normal and
emergency situations and through understanding of the accident causation model.
When referring to the air crew the same principles may be applied also to other
jobs/positions within the Company.
1.10.2.2 The Meaning of Human Factors
The human element is the most flexible, adaptable and valuable part of JC Airlines
system. But it is also the most vulnerable to influence, which can adversely affect its
performance. Lapses in human performance are cited as causal factors in the majority of
incidents/accidents, which are commonly attributed to “Human Error”.
Human Factors have been progressively developed to enhance the safety of complex
systems by promoting the understanding of the predictable human limitations and its
CHAPTER 1 P: 1-34
applications in order to properly manage the ‘human error’. It is only when seeing such an
error from a complex system viewpoint that we can identify the causes that lead to it and
address those causes.
The term “ergonomics” is derived from the Greek words “ergon” (work) and “nomos”
(natural law). It is defined as “the study of the efficiency of persons in their working
environment”. It is often used by aircraft manufacturers and designers to refer to the study
of human machine system design issues (e.g. pilot - cockpit, cabin crew - galley, etc.).
1.10.2.3 The SHEL Model
To best illustrate the concept of Human Factors the SHEL model is being used. The name
SHEL is derived from the initial letters of the models components (Software, Hardware,
Environment, and Liveware). The model uses blocks to represent the different components
of Human Factors and is then built up one block at a time, with a pictorial impression being
given of the need for matching the components.
When applied to JC Airlines, the components will stand for:
S = Software (procedures, manuals checklists, drills, etc.);

H = Hardware (the aircraft and its components e.g. seats, controls, lay-outs, etc.);
E = Environment (the situation in which the L-H-S should function e.g. weather, working
conditions, etc.);
L = Livewire (human element – interaction with other crew members, ground staff, ATC
controller, etc.).

CHAPTER 1 P: 1-35
Air crew work is a continuous interaction between all those elements. Diagram matching
those elements is as important as the characteristics of blocks themselves. On a daily
basis every staff member is the middle ‘L’ who has to interact with the other elements to
form a single block. As such, any mismatch between the blocks can be a source of human
error.
What is Human Factors?

• It studies people working together in concert with machines;
• It aims at achieving safety and efficiency by optimizing the role of people whose
activities relate to complex hazardous systems;
• A multidisciplinary field devoted to optimizing human performance and reducing
human error;
• It incorporates the methods and principles of the behavioural and social sciences,
physiology and engineering.
1.10.2.4 The Aim of Human Factors
By studying the SHEL model of Human Factors we notice that the ‘liveware’ constitutes a
hub and the remaining components must be adapted and matched to this central
component. In aviation, this is vital, as errors can be deadly. For that, manufacturers study
the liveware - hardware interface when designing a new machine and its physical
components. Seats are designed to fit the sitting characteristics of the human body,
controls are designed with proper movement, instruments lay-out and information provided
are designed to match the human being characteristics, etc.
The task is even harder since the liveware, the human being, adapts to mismatches, thus
making any mismatch without removing it, and constituting as such a potential hazard.
Examples of that are the 3 pointer altimeters, the bad seating lay-out in cabins that can
delay evacuation, etc. It is current common practice for manufacturers to encourage
airlines and professional unions to participate in the design phase of aircraft in order to
cater for such issues.
The other component which continuously interact with the liveware is the software, i.e. all
non-physical aspects of the system such as procedures, check-list layout, manuals, and all
what is introduced whether to regulate the whole or part of the SHEL interaction process or
to create defences to cater for deficiencies in that process. Nevertheless, problems in this
interface are often more tangible and consequently more difficult to resolve (e.g.
misinterpretation of a procedure, etc.).
One of the most difficult interfaces to match in the SHEL model is the liveware -
environment part. JC Airlines system operates within the context of broad social, political,
economical and natural constraints that are usually beyond the control of the central
liveware element, but those aspects of the environment will interact in this interface. While
part of the environment has been adapted to human requirements (pressurization and air

CHAPTER 1 P: 1-36
conditioning systems, sound-proofing, etc.) and the human element adapts to natural
phenomena (weather avoidance, turbulence, etc.), the incidence of social, political and
economical constraints is central on the interface and should be properly considered and
addressed by those in management with enough power to alter the outcome and smooth
the match.
The liveware - liveware interface represents the interaction between the human elements.
Adding proficient and effective individuals together to form a group or a set of views does
not automatically imply that the group will function in a proficient and effective way unless
they can function as a team. For them to successfully do so we need leadership, good
communication, crew-cooperation, teamwork and personality interactions, Crew Resource
Management (CRM) and Line Oriented Flight Training (LOFT) are designed to accomplish
that goal.
When advanced, CRM becomes Corporate or Company Resource Management, since

staff/management relationships are within the scope of this interface, as corporate climate
and company operating pressures can significantly affect human performance.
In brief, Human Factors in JC Airlines aim at increasing the awareness of the human
element within the context of the system and provide the necessary tools to perfection the
match of the SHEL concept. By doing so it aims at improving safety and efficiency.
1.10.2.5 Safety and Efficiency
Safety and efficiency are so closely interrelated that in many cases their influences overlap
and factors affecting one may also affect the other. Human Factors have a direct impact
on those two broad areas.
Safety is affected by the liveware - hardware interface. Should a change affect such
interface the result might be catastrophic. In a particular aircraft accident, one causal factor
cited in the report was that “variation in panel layout amongst the aircraft in the fleet had
adversely affected crew performance”.
Safety is also affected by the liveware - software interface. Wrong information set in the
database and unnoticed by the crew or erroneously entered by them can result in a
tragedy. In a case where an aircraft crashed into terrain, information transfer and data
entry errors were committed by navigation personnel and unchecked by flight crew were
among the causal factors.
The liveware - liveware interface also plays a major role in safety. Failure to communicate
vital information can result in aircraft and life loss. In one runway collision,
misinterpretation of verbal messages and a breakdown in normal communication
procedures were considered as causal factors.

CHAPTER 1 P: 1-37
Finally, safety is affected by the liveware - environment interface. Such interface is not only
limited to natural, social or economical constraints; it is also affected by the political climate
which could lead to a tragedy beyond the control of the crew. An airworthy aircraft which
“had been maintained in compliance with the regulations” and flown by “properly licensed
and medically fit crew” disintegrated in-flight due to “the detonation of an improvised
explosive device located in a baggage container”.
Efficiency is also directly influenced by Human Factors and its application. In turn it has a
direct bearing on safety:
• Motivation constitutes a major boost for individuals to perform with greater
effectiveness, which will contribute to a safe operation;
• Properly trained and supervised crew members working in accordance to SOPs are
likely to perform more efficiently and safely;
• Cabin crew understanding of passenger’s behaviour and the emotions they can
expect on board is important in establishing a good relationship which will improve
the efficiency of service, but will also contribute to the efficient and safe handling of
emergency situations;
• The proper layout of displays and controls in the cockpit enhances flight crew
efficiency while promoting safety.
1.10.2.6 Factors Affecting Air Crew Performance
Although the human element is the most adaptable component of JC Airlines system that
component is influenced by many factors which will affect human performance such as:
• Fatigue;
• Health;
• Stress.
These factors are affected by environmental constraints like temperature, noise, humidity,
light, vibration, working hours and load.
Fatigue may be physiological whenever it reflects inadequate rest, as well as a collection

of symptoms associated with disturbed rest. It may also be psychological as a result of
emotional stress, even when adequate physical rest is taken. Acute fatigues are induced
by long duty periods or an accumulation of particularly demanding tasks performed in a
short period of time. Chronic fatigue is the result of cumulative effects of fatigue over the
longer term. Temperature, humidity, noise, workstation design and hypoxia are all
contributing factors to fatigue.
Certain pathological conditions (heart attacks, gastrointestinal disorders, etc.) have caused
sudden pilot incapacitation and in rare cases have contributed to accidents. But such
incapacitation is usually easily detectable by other crew members and taken care of by
applying the proper procedures.

CHAPTER 1 P: 1-38
The more dangerous type is developed when a reduction in capacity results in a partial or
subtle incapacitation. Such incapacitation may go undetected, even by the person
affected, and is usually produced by fatigue, stress, the use of some drugs and medicines
and certain mild pathological conditions such as hypoglycemia. As a result of such health
conditions, human performance deteriorates in a manner that is difficult to detect and
therefore, has a direct impact on flight safety.
Even though crew members are subjected to regular periodical medical examinations to
ensure their continuing health, that does not relieve them from the responsibility to take all
necessary precautions to maintain their physical fitness. It hardly needs to be mentioned
that fitness has favourable effects on emotions, it reduces tension and anxiety and
increases resistance to fatigue. Factors known to positively influence fitness are exercise,
healthy diet and good sleep/rest management. Tobacco, alcohol, drugs, stress, fatigue
and unbalanced diet are all recognized to have damaging effects on health. Finally, it is
each individual responsibility to arrive at the workplace “fit to fly”.
Stress can be found in different jobs, and many Company's job positions are particularly
“rich” in potential stressors. Some of these stressors could be weather phenomena or in-
flight emergencies, others like noise, vibration and G forces have been reduced with the
advent of the jet age while disturbed circadian rhythms and irregular night flying have
increased.
Stress is also associated with life events which are independent from JC Airlines system
but tightly related to the human element. Such events could be sad ones like a family
separation, or happy ones like weddings or childbirth. In all situations, individual responses
to stress may differ from a person to another, and any resulting damage should be
attributed to the response rather than the stressor itself.
In an air crew environment, individuals are encouraged to anticipate, recognize and cope
with their own stress and perceive and accommodate stress in others, thus managing
stress to a safe end. Failure to do so will only aggravate the stressful situation and might
lead to problems.
1.10.2.7 Personality vs. Attitude
Personality traits and attitudes influence the way we behave and interact with others.
Personality traits are innate or acquired at a very young age. They are deep-rooted, stable
and resistant to change. They define a person and classify him (e.g. ambitious, dominant,
aggressive, mean, nice, etc.).
On the contrary, attitudes are learned and enduring tendencies or pre-dispositions to

respond in a certain way, the response is the behaviour itself. Attitudes are more
susceptible to change through training, awareness or persuasion.

CHAPTER 1 P: 1-39
The initial screening and selection process of air crew aims at detecting undesired
personality characteristics in the potential crew member in order to avoid problems in the
future.
Human Factors training aims at modifying attitudes and behaviour patterns through
knowledge, persuasion and illustration of examples, revealing the impact of attitudes and
behaviour on flight safety. That should allow the air crew to make rapid decisions on what
to do when facing certain situations.
1.10.2.8 Crew Resource Management (CRM)
CRM is a practical application of Human Factors. It aims at teaching crew members how to
use their interpersonal and leadership styles in ways that foster crew effectiveness by
focusing on the functioning of crew members as a team, not only as a collection of
technically competent individuals, i.e. it aims at making air crew work in “synergy” (a
combined effect that exceeds the sum of individual effects).
Changes in most airlines community have been drastic throughout this century: the jet
age, aeroplane size, sophisticated technology, deregulation, hub and spokes, security
threats, industrial strikes and supersonic flights. In every one of those changes some
people saw a threat; it made them anxious, even angry sometimes.
When first introducing CRM some people might see a threat, since it constitutes a
‘change’. However, with the majority of accidents having lapses in human performance as
a contributing causal factor, and with nearly two decades of CRM application in the
international aviation community revealing a very positive feedback, we see this ‘change'
as “strength”.
CRM can be approached in many different ways; nevertheless there are some essential
features that shall be addressed: The concept must be understood, certain skills must be
taught and inter-active group exercises must be accomplished.
To understand the concept one must be aware of certain topics as synergy, the effects of
individual behaviour on the team work, the effect of complacency on team efforts, the
identification and use of all available resources, the statutory and regulatory position of the
pilot-in-command as team leader and commander, the impact of company culture and
policies on the individual and the interpersonal relationships and their effect on team work.
Skills to be developed include:

• Communication skills: Effective communication is the basis of successful teamwork.
Barriers to communication are explained, such as cultural difference, rank, age,
crew position, and wrong attitude. Aircrews are encouraged to overcome such
barriers through self-esteem, participation, polite assertiveness, legitimate avenue
of dissent and proper feedback.

CHAPTER 1 P: 1-40
• Situational Awareness: Total awareness of surrounding environment is emphasized

so is the necessity from the crew member to differentiate between reality and
perception of reality, to control distraction, enhance monitoring and cross-checking
and to recognize and deal with ones or others incapacitation, especially when
subtle.
• Problem Solving and Decision Making: That skill aims at developing conflict
management within a time constraint. A conflict could be immediate or ongoing, it
could require a direct response or certain tact to cope with it. By developing air crew
judgment within a certain time frame, we develop skills required to bring conflicts to
safe ends.
• Leadership: In order for a team to function efficiently it requires a leader. Leadership
skills derive from authority but depend for their success on the understanding of
many components such as managerial and supervisory skills that can be taught and
practiced, realizing the influence of culture on individuals, maintaining an
appropriate distance between team members enough to avoid complacency without
creating barriers, care for one’s professional skill and credibility, the ability to hold
the responsibility of all crew members and the necessity of setting the good
example. The improvement of these skills will allow the team to function more
efficiently by developing the leadership skills required to achieve a successful and
smooth followership in the team.
• Stress Management: Commercial pressure, mental and physical fitness to fly,
fatigue, social constraints and environmental constraints are all part of our daily life
and they all contribute in various degrees to stress. Stress management is about
recognizing those elements; dealing with one’s stress and help others manage their
own. It is only by accepting things that are beyond our control, changing things that
we can and knowing the difference between both that we can safely and efficiently
manage stress.
• Critique: Discussion of cases and learning to comment and critique actions are both
ways to improve one’s knowledge, skills and understanding. Review of actual airline
accidents and incidents to create problem-solving dilemmas that participant air crew
should act-out and critique through the use of feed-back system will enhance crew
members’ awareness of their surrounding environment, make them recognize and
deal with similar problems and help them solve situations that might occur to them.
Finally, for a CRM program to be successful it must be embedded in the total training
program, it must be continuously reinforced and it must become an inseparable part of the
organizations culture. CRM should thus be instituted as a regular part of periodical training
and should include practice and feedback exercises such as complete crew LOFT
exercises.
LOFT is considered to be an integral part of CRM training, where the philosophy of CRM
skills is reinforced. LOFT refers to air crew training which involves a full mission simulation
of situations which are representative of line operations, with emphasis on situations which
involve communication, management and leadership. As such it is considered as a

CHAPTER 1 P: 1-41
practical application of the CRM training and should enhance the principles developed
therein and allow a measurement of their effectiveness.
1.10.3 Cultural Factors
Aviation safety must transcend national boundaries, including all the cultures therein. On a
global scale, the aviation industry has achieved a remarkable level of standardization
across aircraft types, countries and peoples. Nevertheless, it is not difficult to detect
differences in how people respond in similar situations. As people in the industry interact
(the Liveware-Liveware (L-L) interface), their transactions are affected by the differences in
their cultural backgrounds. Different cultures have different ways of dealing with common
problems.
It is important to understand the different cultures at work in an airline. Culture influences

the values, beliefs and behaviours of individuals within a particular group. Culture is the
social conditioning of an individual. It provides clues as to way an individual behaves in
normal and non-normal circumstances within a group. Culture is the complex social
dynamic that sets the rules of the game.
Organisations are not immune to cultural considerations. Organizational behaviour is

subject to these influences at every level. The following three levels of culture have
relevance to safety management initiatives:
a) National culture recognizes and identifies the national characteristics and value
systems of particular nations. People of different nationalities differ, for example, in
their response to authority, how they deal with uncertainty and ambiguity, and how they
express their individuality. They are not all attuned to the collective needs of the group
(team or organization) in the same way. In collectivist cultures, there is acceptance of
unequal status and deference to leaders. Such factors may affect the willingness of
individuals to question decisions or actions - an important consideration in CRM. Work
assignments that mix national cultures may also affect team performance by creating
misunderstandings;
b) Professional culture recognizes and identifies the behaviour and characteristics of

particular professional groups. Through personnel selection, education and training,
on-the-job experience, etc., professionals (e.g. pilots) tend to adopt the value system
of, and develop behaviour patterns consistent with, their peers; they learn to “walk and
talk” alike. They generally share a pride in their profession and are motivated to excel
in it. On the other hand, they frequently have a sense of personal invulnerability, e.g.
they feel that their performance is not affected by personal problems and that they do
not make errors in situations of high stress;

CHAPTER 1 P: 1-42
c) Organisational culture recognizes and identifies the behaviour and values of particular
organisations (e.g. the behaviour of members of one company versus that of another
company). Organisations provide a shell for national and professional cultures. In an
airline, for example, pilots may come from different professional backgrounds (e.g.
military versus civilian experience, and bush or commuter operations versus
development within a large carrier). They may also come from different organizational
cultures due to corporate mergers or layoffs.
The three cultural sets described above determine, for example, how juniors will relate to
their seniors, how information is shared, how personnel will react under stress, how
particular technologies will be embraced, how authority will be acted upon and how
organizations react to human errors (e.g. punish offenders or learn from experience).
Culture will be a factor in how automation is applied, how procedures (SOPs) are
developed, how documentation is prepared, presented, and received, how training is
developed and delivered, how work assignments are made; relationships between pilots
and Air Traffic Control (ATC), etc. In other words, culture impacts on virtually every type of
interpersonal transaction. In addition, cultural considerations creep into the design of
equipment and tools. Technology may appear to be culture-neutral, but it reflects the
biases of the manufacturer (e.g. consider the English language bias implicit in much of the
world’s computer software). Yet, there is no right and no wrong culture - they are what they
are and they each possess a blend of strengths and weaknesses.
1.10.4 Corporate Safety Culture
As seen above, many factors create the context for human behaviour in the workplace.
Organizational or corporate culture sets the boundaries for accepted human behaviour in
the workplace by establishing the behavioural norms and limits. Thus, organizational or
corporate culture provides a cornerstone for managerial and employee decision-making.
Safety culture in an organisation can be described as the way in which it conducts its
business and particularly the way it manages safety. Safety culture is the product of
individual and group values, attitudes, competencies and patterns of behaviour that
determine the commitment, the style and proficiency of the organisation's management of
safety. Organisations with a positive safety culture are characterized by communications
founded on mutual trust, by shared perceptions of the importance of safety, and by
confidence in the efficiency of preventive measures.
Positive safety cultures typically are:

• Informed Culture: In an informed culture, the organisation collects and analyses
relevant data, and actively disseminates safety information to staff. Management
fosters a culture where people understand the hazards and risks inherent in their
areas of operation. Personnel are provided with the necessary knowledge, skills
and job experience to work safely, and they are encouraged to identify the threats
to their safety and to seek the changes necessary to overcome them;

CHAPTER 1 P: 1-43
• Reporting Culture: A reporting culture means a cultivating atmosphere where

people have confidence to report safety concerns without fear of blame. Managers
and operational personnel freely share critical safety information without the threat
of punitive action. This is frequently referred to as creating a corporate reporting
culture. Personnel are able to report hazards or safety concerns as they become
aware of them, without fear of sanction or embarrassment. Employees must know
that confidentiality will be maintained and that the information they submit will be
acted upon;
• Learning Culture: A learning culture means that an organisation is able to learn from
its mistakes and make changes. Personnel are encouraged to develop and apply
their own skill and knowledge to enhance organization safety. Personnel are
updated on safety issues and incidents outcomes so that everyone learns the
lessons. Learning is seen as more than a requirement for initial skills training; rather
it is valued as a lifetime process. People are encouraged to develop and apply their
own skills and knowledge to enhance organizational safety. Personnel are updated
on safety issues by management, and safety reports are fed back to staff so that
everyone can learn the pertinent safety lessons;
• Just Culture: Just culture is safety culture in which errors and unsafe acts will not be
punished if the error was unintentional. However, those who act recklessly or take
deliberate and unjustifiable risks will still be subject to disciplinary action. While a
non-punitive environment is fundamental for a good reporting culture, the workforce
must know and agree on what is acceptable and what is unacceptable behaviour;
• Flexible Culture: A flexible culture is one where the organisation and the people in it
are capable of adapting effectively to changing demands.
Characteristics of different safety cultures

CHAPTER 1 P: 1-44
1.10.5 Human Error

1.10.5.1 General
Human error is cited as being a causal or contributing factor in the majority of aviation
occurrences. All too often competent personnel commit errors, although clearly they did
not plan to have an accident. Errors are not some type of aberrant behaviour; they are a
natural bi-product of virtually all human endeavours. Error must be accepted as a normal
component of any system where humans and technology interact.
Given the rough interfaces of the aviation system (as depicted in the SHEL model), the
scope for human errors in aviation is enormous. Understanding how normal people commit
errors is fundamental to safety management. Only then can effective measures be
implemented to minimize the effects of human errors on safety.
Even if not altogether avoidable, human errors are manageable through the application of
improved technology, relevant training, and appropriate regulations and procedures. Most
measures aimed at error management involve front-line personnel. However, the
performance of pilots, etc. can be strongly influenced by organizational, regulatory, cultural
and environmental factors affecting the workplace. For example, organizational processes
constitute the breeding grounds for many predictable human errors, including inadequate
communication facilities, ambiguous procedures, unsatisfactory scheduling, insufficient
resources, and unrealistic budgeting - in fact, all processes that the organization can
control. Below in the figure are summarized some of the factors contributing to human
errors - and to accidents.
Contributing factors to human error

CHAPTER 1 P: 1-45
1.10.5.2 Error Types
Errors may occur:

• At the planning stage; or
• During the execution of the plan.
Planning errors lead to mistakes; either the person follows an inappropriate procedure for
dealing with a routine problem or builds a plan for an inappropriate course of action to
cope with a new situation. Even when the planned action is appropriate, errors may occur
in the execution of the plan. The Human Factors literature on such errors in execution
generally draws a distinction between slips and lapses. A slip is an action which is not
carried out as planned and will therefore always be observable. A lapse is a failure of
memory and may not necessarily be evident to anyone other than the person who
experienced the lapse.
Planning Errors (Mistakes)

In problem solving, we intuitively look for a set of rules (SOPs, rules of thumb, etc) that are
known and have been used before and that will be appropriate to the problem in hand.
Mistakes can occur in two ways:

• The application of a rule that is not appropriate to the situation; or
• The correct application of a rule that is flawed.
Misapplication of good rules - this usually happens when an operator is faced with a
situation that exhibits many features common to the circumstances for which the rule was
intended, but with some significant differences. If the significance of the differences is not
recognized, an inappropriate rule may be applied.
Application of bad rules - this involves the use of a procedure that past experience has
shown to work but that contains unrecognized flaws. If such a solution works in the
circumstances under which it was first tried, it may become part of the individual’s regular
approach to solving that type of problem.
When a person does not have a ready-made solution based on previous experience
and/or training, that person draws on personal knowledge and experience. Developing a
solution to a problem using this method will inevitably take longer than applying a rule-
based solution, as it requires reasoning based on knowledge of basic principles. Mistakes
can occur because of a lack of knowledge or because of faulty reasoning. The application
of knowledge-based reasoning to a problem will be particularly difficult in circumstances
where the individuals are busy, as their attention is likely to be diverted from the reasoning
process to deal with other issues. The probability of a mistake occurring becomes greater
in such circumstances.

CHAPTER 1 P: 1-46
Errors can be divided into the two following categories:

• Slips and lapses are failures in the execution of the intended action. Slips are
actions that do not go as planned, while lapses are memory failures. For example,
operating the flap lever instead of the (intended) gear lever is a slip. Forgetting a
checklist item is a lapse;
• Mistakes are failures in the plan of action. Even if execution of the plan were
correct, it would not have been possible to achieve the intended outcome.
Slips and lapses (execution errors): The actions of experienced and competent personnel
tend to be routine and highly practiced; they are carried out in a largely automatic fashion,
except for occasional checks on progress. Slips and lapses can occur as the result of:
a) Attentional slips. These occur as the result of a failure to monitor the progress of a
routine action at some critical point. They are particularly likely when the planned
course of action is similar, but not identical, to a routinely used procedure. If
attention is allowed to wander or a distraction occurs at the critical point where the
action differs from the usual procedure, the result can be that the operator will follow
the usual procedure rather than the one intended in this instance;
b) Memory lapses. These occur when we either forget what we had planned to do, or
omit an item in a planned sequence of actions;
c) Perceptual errors. These are errors in recognition. They occur when we believe we
saw or heard something which is different from the information actually presented.
Errors versus Violations
Errors, which are a normal human activity, are quite distinct from violations. Both can lead
to a failure of the system. Both can result in a hazardous situation. The difference lies in
the intent. A violation is a deliberate act, while an error is unintentional.
A violation is defined as “a deliberate act of wilful misconduct or omission resulting in a

deviation from established regulations, procedures, norms or practices”.
Sometimes individuals may knowingly deviate from norms, in the belief that the violation
facilitates mission achievement without creating adverse consequences. Violations of this
nature are errors in judgement and may not automatically result in disciplinary measures
depending on the policies in place. Violations of this type can be categorized as follows:
a) Situational violations are committed in response to factors experienced in a specific
context, such as time pressure or high workload.
b) Routine violations become the normal way of doing business within a work group.
Such violations are committed in response to situations in which compliance with
established procedures makes task completion difficult. This may be due to
practicality/workability issues, deficiencies in human-technology interface design
and other issues that cause persons to adopt “workaround” procedures, which
eventually become routine. These deviations, referred to as “drift”, may continue

CHAPTER 1 P: 1-47
without consequence, but over time they may become frequent and result in
potentially severe consequences. In some cases routine violations are well
grounded and may result in the incorporation of the routine violation as an accepted
procedure after a proper safety assessment has been conducted and it is shown
that safety is not compromised.
c) Organizationally induced violations may be considered as an extension of routine
violations. This type of violation tends to occur when an organization attempts to
meet increased output demands by ignoring or stretching its safety defences.
1.10.6 Bias
Everyone’s judgment is shaped by personal experience and cultural conditioning. Bias is

the tendency to apply a particular response regardless of the situation. The following are
some of the common biases that can affect the validity of safety analyses:
• Frequency bias;
• Selectivity bias;
• Familiarity bias;
• Conformity bias;
• Committee conformity bias;
• Overconfidence bias.
Frequency Bias: Individuals tend to over/under estimate the probability of occurrence of a

particular event because our evaluation is based solely on our personal experience and
conditioning.
Selectivity Bias: Our personal preferences may cause us to select items based on a
restricted core of facts. We have a tendency to ignore those facts that don’t fit the mental
pattern we expect. We may focus on the more obvious facts for example, loud noise,
bright light, most recent event and ignore cues as the more subtle facts that can provide
relevant information about the nature of the event.
Familiarity Bias: In any given situation we tend to choose the most familiar solutions or
patterns. We tend to do things in accordance with patterns of our previous experience,
even if they are not the best solutions for the current situation. For example we may drive
to work using the same route every day even though there may be a shorter route
available.
Conformity Bias: We have a tendency to look for a solution that fit our decision rather than
look for solutions that contradict it. As the strength of our mental model grows we are
reluctant to accept facts that do not fit that mental model that we already know.
Committee Conformity Bias: Most of us have a tendency to fall into line with the majority
view. We do not want to break the Committee’s harmony by disagreeing.

CHAPTER 1 P: 1-48
Overconfidence Bias: There is a tendency to overestimate the extent of our knowledge of

a situation and the likely outcome. The result is we tend to ignore the facts that we don’t
accept as valid, even if in fact they are.

CHAPTER 1 P: 1-49
1.11 SMS IMPLEMENTATION PLAN
1.11.1 General
JC Airlines’ SMS Implementation Plan should include a total description of the activities to
be performed in connection with the development and implementation of a Safety
Management System (SMS). The SMS Implementation Plan does not include any
activities related to the maintenance of a SMS, as this will have to be procedures
implemented as an integrated part of the SMS.
SMS Implementation Plan shall be developed in its first version when the implementation
of the Safety Management Systems is initiated. The plan shall be reviewed on at least
yearly basis and whenever a major event occurs in connection with the implementation.
Each update of the original version shall be agreed and signed by duly authorities which
mean the management of the organization. Only through this, the management
commitment to the implementation of the Safety Management System can be ensured. A
track record of the changes to the SMS Implementation Plan should be developed in order
to ensure traceability.
1.11.2 Overview of the SMS Implementation Plan
The objective of JC Airlines’ SMS Implementation Plan is to finalize and implement the
Safety Management System in the Company based on the available baseline developed
as a part of the safety project and as defined in subsection 1.11.3.
Furthermore the objective of SMS Implementation Plan is to develop and strengthen the
safety culture, to define the overall safety performance targets and finally to ensure the
lesson dissemination and the safety awareness.
JC Airlines’ Safety Policy is part of SMS Implementation Plan – refer to section 1.2 Safety
Policy for details.
The success of the proposed SMS implementation plan depends on the support,
commitment and participation of management, as well as operations personnel. A phase
approach is suggested for the development of the SMS implementation plan and the
timeline for its implementation may be different, depending the complexity of the
organization.
JC Airlines’ SMS Implementation Plan is fully endorsed by the Company’s Accountable

Manager.
SMS implementation plan shall address the coordination between the JC Airlines’ SMS
and the SMS of external organizations where applicable.

CHAPTER 1 P: 1-50
SMS Implementation Plan (example):
Based on the size of the company and complexity of the service SMS implementation
should normally take 3 years. There should be an additional 2 years to consolidate
processes re-aligning them based on initial experience, etc. From then on its normal
maintenance and adjustments to new developments in the environment.
A model Gantt chart on the implementation of SMS plan is used by the Safety Department.
It is being constantly reviewed and updated.
SMS Implementation Plan – building blocks:

1) Safety planning and objectives;
2) Safety policy;
3) Safety roles and responsibilities;
4) System description;
5) Gap analysis;
6) Hazard identification processes;
7) Risk management processes;
8) Safety performance measurement;
9) Safety training;
10) Safety communication;
11) Coordination with third parties;
12) Management review (of safety performance).

CHAPTER 1 P: 1-51
SMS development work plan (example): The following sample work plan is presented to
assist in the tracking of the development of a safety management system. The results of
the Gap Analysis process should be used to modify it to fit the specific requirements.

CHAPTER 1 P: 1-52

CHAPTER 2 P: 2-1
SAFETY RISK MANAGEMENT Rev. 00, 10 JAN 2017
2 SAFETY RISK MANAGEMENT

2.1 GENERAL
The aviation industry faces a diversity of risks every day, many capable of compromising
the viability of an operator, and some even posing a threat to the industry. Indeed, risk is a
by-product of doing business. Not all risks can be eliminated, nor are all conceivable risk
mitigation measures economically feasible. The risks and costs inherent in aviation
necessitate a rational process for decision-making. Daily, decisions are made in real time,
weighing the probability and severity of any adverse consequences implied by the risk
against the expected gain of taking the risk. This process is known as safety risk
management.
Hazard becomes a risk because of:

• People;
• Procedures;
• Aircraft and equipment;
• Acts of nature.
People present the biggest risk for such reasons as:

• Attitude;
• Motivation;
• Perception;
• Ability.
A safety programme, through its methods of recording and monitoring safety related
occurrences and audit procedures can be considered to be a continuous risk management
process.
Safety risk management can be defined as the identification, analysis and elimination
(and/or mitigation to an acceptable or tolerable level) of those hazards, as well as the
subsequent risks, that threaten the viability of an organisation. In other words, risk
management facilitates the balancing act between assessed risks and viable risk
mitigation. It ensures an analysis of the Company’s resources and goals and allows for a
balanced and realistic allocation of resources between safety and operational goals, which
supports the overall service delivery needs of the Company.
Company departments will employ safety risk management principles during the course of
their safety management. Each operational department in the fulfilment of the
requirements of the safety risk management has to ensure hazards are analysed in order
to determine the existing and potential safety risk to aircraft operations. Safety risks are
assessed to determine the requirement for risk mitigation action.

CHAPTER 2 P: 2-2
Safety risk management involves managing to achieve an appropriate balance between

realizing opportunities for gains while minimizing losses. It is an integral part of good
management practice and an essential element of good corporate governance. It is an
iterative process consisting of steps that, when undertaken in sequence, enable
continuous improvement in decision-making and facilitate continuous improvement in
performance.
Safety Manager shall ensure that an appropriate infrastructure and culture and the
application of a logical and systematic method of establishing the context, identifying,
analysing, evaluating, treating, monitoring and communicating risks associated with any
activity, function or process in a way that enables the Company to minimize losses and
maximize gains.
To be most effective, safety risk management shall be part of airline's culture. It shall be
embedded into airline's philosophy, practices and operational processes rather than be
viewed or practiced as a separate activity. When this is achieved, everyone in the airline
shall be involved in the management of risk.
Although the concept of risk is often interpreted in terms of hazards or negative impacts,
Safety Manager shall ensure airline’s Safety Management System (SMS) is concerned
with risk as exposure to the consequences of uncertainty, or potential deviations from what
is planned or expected. Safety Manager shall ensure risk is managed effectively and
efficiently such that the airline is more likely to achieve its objectives at lower overall cost.
Safety Manager shall ensure that risk management is applied at all stages in the life of an
activity, function, project, product or asset. The maximum benefit is usually obtained by
applying the risk management process from the beginning. Often a number of discrete
studies are carried out at different times, and from strategic and operational perspectives.
The process described in this chapter applies to the management of both potential gains
and potential losses.
The goal of airline’s safety risk management process is to provide guidance to enable
airline to achieve:
• A more confident and rigorous basis for decision-making and planning;
• Better identification of opportunities and threats;
• Gain value from uncertainty and variability;
• Pro-active rather than re-active management;
• More effective allocation and use of resources;
• Improved incident management and reduction in loss and the cost of risk, including
commercial insurance premiums;
• Improved stakeholder confidence and trust;
• Improved compliance with relevant legislation;
• Better corporate governance.

CHAPTER 2 P: 2-3
Safety risk management is an integral component of safety management. It involves a

logical process of objective analysis, particularly in the evaluation of the risks.
Safety risk management comprises three essential elements:

• Hazard identification;
• Risk assessment;
• Risk mitigation.
Safety risk management process

CHAPTER 2 P: 2-4
Safety risk management process (in detail)
It is important to clarify the definition of certain terms in the context of safety risk
management. The following definitions of terms apply:
Consequence Outcome or impact of an event.

Note: There can be more than one consequence from one event.
Consequences can range from positive to negative.
Consequences can be expressed qualitatively or
quantitatively. Consequences are considered in relation to
the achievement of objectives.
Control An existing process, policy, device, practice or other action that acts
to minimize negative risk or enhance positive opportunities.
Note: The word “control” may also be applied to a process designed
to provide reasonable assurance regarding the achievement of
objectives.
Hazard A source of potential harm.
Likelihood Used as a general description of probability or frequency.

Note: Likelihood can be expressed qualitatively or quantitatively.
Probability A measure of the chance of occurrence expressed as a number

between 0 and 1.
CHAPTER 2 P: 2-5
Residual Risk Risk remaining after implementation of risk treatment.
Risk The chance of something happening that will have an impact on

objectives.
Note: A risk is often specified in terms of an event or circumstance
and the consequence that may flow from it. Risk may have a positive
or negative impact.
Risk Analysis Systematic process to understand the nature of and to deduce the
level o risk.
Note: Risk Analysis provides the basis for risk evaluation and
decisions about risk treatment.
Risk Assessment The overall process of risk identification, risk analysis and risk
evaluation.
Risk Criteria Terms of reference by which the significance of risk is assessed.

Note: Risk Criteria can include associated cost and benefits, legal
and statuary requirements, socioeconomic and environmental
aspects, the concerns of stakeholders, priorities and other inputs to
the assessment.
Risk Evaluation Process of comparing the level of risk against risk criteria.
Note: Risk evaluation assists in decisions about risk treatment.
Risk Management The culture, processes and structures that are directed towards
realizing potential opportunities whilst managing adverse effects.
Risk Reduction Actions taken to lessen the likelihood, negative consequences, or

both, associated with a risk.
Risk Treatment Process of selection and implementation of measures to modify risk.

Note: The term “Risk Treatment” is sometimes used for the
measures themselves. Risk Treatment measures can include
avoiding, modifying, sharing or retaining risk.
Stakeholders Those people and organisations who may affect, be affected by, or
perceive themselves to be affected by a decision, activity or risk.
Given the total costs of aviation accidents, many diverse groups have a stake in improving
the management of safety. The principal stakeholders in safety are listed below:
• Aviation professionals (e.g. flight crew, cabin crew, etc);
• Aircraft owners and operators;
• Manufacturers (especially airframe and engine manufacturers);
CHAPTER 2 P: 2-6
• Aviation regulatory authorities (e.g. SSCA);

• Industry trade associations (e.g. IATA);
• Regional ATS providers;
• Professional associations and unions (e.g. IFALPA);
• International aviation organizations (e.g. ICAO);
• Investigative agencies (e.g. United States NTSB);
• The flying public.
Major aviation safety occurrences invariably involve additional groups which may not
always share a common objective in advancing aviation safety, for example:
• Next of kin, victims, or persons injured in an accident;
• Insurance companies;
• Travel industry;
• Safety training and educational institutions;
• Other government departments and agencies;
• Elected government officials;
• Investors;
• Coroners and police;
• Media;
• General public;
• Lawyers and consultants;
• Diverse special interest groups.
The benefits of safety risk management are:

• Safer operation;
• Cost savings;
• Reduced claims;
• Establishment of a healthy safety risk management culture;
• An enhanced reputation;
• More business.

CHAPTER 2 P: 2-7
2.2 HAZARD IDENTIFICATION
Hazard is a condition, object or activity with the potential of causing injuries to personnel,
damage to equipment or structure, loss of material or reduction of ability to perform a
prescribed function. Given that a hazard may involve any situation or condition that has the
potential to cause adverse consequences, the scope for hazards in aviation is wide. The
following are some examples:
• Design factors, including equipment and task design;
• Procedures and operating practices, including their documentation and checklists,
and their validation under actual operating conditions;
• Communications, including the medium, terminology and language;
• Personnel factors, such as company policies for recruitment, training and
remuneration;
• Organizational factors, such as the compatibility of production and safety goals, the
allocation of resources, operating pressures and the corporate safety culture;
• Work environment factors, such as ambient noise and vibration, temperature,
lighting;
• Regulatory oversight factors, including the applicability and enforceability of
regulations; the certification of equipment, personnel and procedures; and the
adequacy of surveillance audits;
• Defences, including such factors as the provision of adequate detection and
warning systems, the error tolerance of equipment and the extent to which the
equipment is hardened against failures.
Hazards are not necessarily damaging or negative components of a system. It is only

when hazards interface with the operations of the system aimed at service delivery that
their damaging potential may become a safely concern.
Hazards may be grouped into three generic groups:

• Natural hazards;
• Technical hazards;
• Economic hazards.
Natural hazards are a consequence of the habitat or environment within which operations
related to the provision of services take place.
Technical hazards are a result of energy sources (electricity, fuel, hydraulic pressure, etc.)
or safety critical functions (potential for hardware failures, software glitches, warnings, etc.)
necessary for operations related to the delivery of services. Examples of technical hazards
include deficiencies regarding aircraft and aircraft components, systems and related
equipment, Company's facilities, tools arid related equipment and/or facilities, systems and
related equipment that are external to the Company.

CHAPTER 2 P: 2-8
Economic hazards are the consequence of the socio-political environment within which
operations related to the provision of services take place. Examples of economic hazards
include growth, recession and cost of material or equipment.
The Company’s safety information management system includes safety assessment

documentation that contains hazard descriptions, the related consequences, the assessed
likelihood and severity of the safety risks, and required safety risk controls. Existing safety
assessments are being reviewed whenever new hazards are identified and proposals for
further safety risk controls are anticipated.
Hazard documentation and follow-up risk management process
Hazards are constantly identified through various data sources. The service provider is
expected to identify hazards, eliminate these hazards or to mitigate the associated risks. In
the case of hazards identified in products or services delivered through subcontractors,
mitigation could be the service provider’s requirement for such organizations to have an
SMS or an equivalent process for hazard identification and risk management.
Hazard identification is the first element in the risk management process. Hazards may be
identified in the aftermath of actual safety events (accidents or incidents), or they may be
identified through proactive and predictive processes aimed at identifying hazards before
they precipitate safety events.

CHAPTER 2 P: 2-9
Hazard identification may be classified as:
a) Reactive
This methodology involves analysis of past outcomes or events. Hazards are
identified through investigation of safety occurrences. Incidents and accidents are
clear indicators of system deficiencies and therefore can be used to determine the
hazards that either contributed to the event or are latent.
Incidents and accidents fall into this category where a safety control or barrier has
been absent, ineffective or breached, resulting in a negative outcome. The incident
is reported into the Safety Management System (SMS) as part of the airline safety
reporting programme. Examples: Air Safety Reports (ASR), Flight Data Monitoring
(FDM) identified exceedance.
b) Proactive
This methodology involves analysis of existing or real-time situations, which is the
primary job of the safety assurance function with its audits, evaluations, employee
reporting, and associated analysis and assessment processes. This involves
actively seeking hazards in the existing processes.
This is the forward looking capability of the SMS which reviews potential risk
precursors. An example of this is the identification of causes from one particular
occurrence, which could also contribute to undesirable outcomes and be common
to other occurrences (i.e. ATC language issues could contribute to a level bust and
a TCAS event). Examples: FDM trends, ASR trends, engine trend monitoring.
c) Predictive
This methodology involves data gathering in order to identify possible negative
future outcomes or events, analysing system processes and the environment to
identify potential future hazards and initiating mitigating actions.
Predictive safety investigations are based on the analysis of multiple sources of
current and historical safety data, often at a level where the signals are weak.
Through understanding how these multiple sources of weak signals correlate,
adverse trends indicating potential emerging hazards can be identified. Examples:
Atypical flight data monitoring trend analysis, LOSA.
There are a variety of sources of hazard identification. Some sources are internal to the
Company while other sources are external to the Company.
Methods of identifying hazards include, but are not limited to:

• Voluntary safety reports;
• Reports required by the Company;
• Formal investigations;
• Input from subject matter experts;
• Analysis of training, operational, and employee performance data;
• Industry sources.

CHAPTER 2 P: 2-10
For the purpose of hazard identification, Safety Manager shall review hazards/threats from
relevant industry reports for follow up actions or risk evaluation where applicable.
The hazard reporting system in JC Airlines is confidential and has provisions to protect the
reporter’s identity.
Hazard identification is a wasted exercise unless safety information is extracted from the
data collected. The first step in developing safety information is hazard analysis. Hazard
analysis is in essence, a three-step process.
First step is to identify the generic hazard. Generic hazard is used as a term that intends to
provide focus and perspective on a safety issue, while also helping to simplify the tracking
and classification of many individual hazards flowing from the generic hazard.
Second step is to break down the generic hazard into specific hazards or components of
the generic hazard. Each specific hazard will likely have a different and unique set of
causal factors, thus making each specific hazard different and unique in nature.
Third step is to link specific hazards to potentially specific consequences, i.e. specific
events or outcomes.
The Safety Manager shall maintain a register (or log) of hazards, and of the corresponding
risk assessments and mitigations. This risk register records hazards per activity and
indicates how these have been addressed in the past and are currently being addressed.
The number or rate of the registered/collected hazard reports should commensurate with
the size and scope of the JC Airlines’ operations.
Any future risk assessment may then draw upon the information already available. The
information is both communicated and made available to all in the Company with special
attention to the managers in charge, depending on the nature of the risks.
The register of “Hazards and Undesirable Events” is updated at each step of the risk
management processes. These registers also record the results of the processes and
serve as a basis for risk monitoring, review and improvement.

CHAPTER 2 P: 2-11
2.3 SAFETY RISK ASSESSMENT

2.3.1 General
Having confirmed the presence of a safety hazard, some form of analysis is required to
assess its potential for harm or damage. Typically, this assessment of the hazard involves
three considerations:
• The probability of the hazard precipitating an unsafe event (i.e. the probability of
adverse consequences should the underlying unsafe conditions be allowed to
persist);
• The severity of the potential adverse consequences, or the outcome of an unsafe
event;
• The rate of exposure to the hazards. The probability of adverse consequences
becomes greater through increased exposure to the unsafe conditions. Thus,
exposure may be viewed as another dimension of probability. However, some
methods of defining probability may also include the exposure element, for
example, a rate of 1 in 1000 hours.
Safety risk is the assessed potential for adverse consequences resulting from a hazard. It
is the likelihood that the hazard’s potential to cause harm will be realized.
Safety risk assessment involves consideration of both the probability and the severity of
any adverse consequences; in other words, the loss potential is determined. In carrying
out risk assessments, it is important to distinguish between hazards (the potential to cause
harm) and risk (the likelihood of that harm being realized within a specified period of time).
A risk assessment matrix is a useful tool for prioritizing the hazards most warranting
attention.
There are many ways - some more formal than others - to approach the analytical aspects
of risk assessment. For some risks, the number of variables and the availability of both
suitable data and mathematical models may lead to credible results with quantitative
methods (requiring mathematical analysis of specific data). However, few hazards in
aviation lend themselves to credible analysis solely through numerical methods. Typically,
these analyses are supplemented qualitatively through critical and logical analysis of the
known facts and their relationships.
The acronym ALARP is used to describe a safety risk that has been reduced to a level that
is as low as reasonably practicable. In determining what is reasonably practicable in the
context of safety risk management, consideration should be given both to the technical
feasibility of further reducing the safety risk, and the cost. This shall include a cost-benefit
analysis. A safety risk being ALARP means that any further risk reduction is either
impracticable or grossly outweighed by the cost. It should, however, be noted that when a
safety risk is “accepted”, this does not mean that the safety risk has been eliminated.
Some residual level of safety risk remains; however, it has accepted that the residual
safety risk is sufficiently low that it is outweighed by the benefits.

CHAPTER 2 P: 2-12
A safety assessment should be undertaken, at a minimum:

• During implementation of the safety management system and then at regular
intervals;
• When major operational changes are planned;
• If the Company is undergoing rapid change, such as growth and expansion, offering
new services, cutting back on existing service, or introducing new equipment or
procedures;
• When key personnel change.
There are several active monitoring methods that can be employed in safety assessment:
• Management safety inspections - To determine the effectiveness of systems and
demonstration of line commitment. Usually achieved through examination of
managers or teams that focus on people’s activities and the system they use;
• Audits - To verify conformance with established guidelines and standards. Usually
achieved through systematic independent review of an organization’s systems
personnel, facilities, etc. using a predetermined targeted scope of coverage. They
tend to be focused at the process level;
• Process and practice monitoring - To identify whether the procedure in use is
relevant and actively used and the practices employed are in line with the
requirements of the procedures;
• Reviews - To provide an overview of the processes involved in a work area or
system for their effectiveness and appropriateness. Resource allocation is often a
target of a review.
In most quality assurance systems, audit checklists are used to collect data related to the
system. The same type of checklist may be utilized to provide a safety assessment of the
Company. This will allow JC Airlines to develop a safety case, an analysis of safety issues
within our company that adequately portrays the safety level of the Company.
Risk assessment reports, after they are produced, shall be approved by departmental
managers or higher level where appropriate.
A periodic review of existing safety risk assessments should be in place within the
Company’s SMS.
2.3.2 Safety Risk Probability
Regardless of the analytical methods used, the probability of causing harm or damage
must be assessed. Risk probability is defined as the likelihood or frequency that a safety
consequence or outcome might occur.

CHAPTER 2 P: 2-13
The determination of likelihood can be aided by questions such as:

• Is there a history of occurrences similar to the one under consideration, or is this
an isolated occurrence?
• What other equipment or components of the same type might have similar
defects?
• How many personnel are following, or are subject to, the procedures in question?
• What percentage of the time is the suspect equipment or the questionable
procedure in use?
• To what extent are there organizational, managerial or regulatory implications
that might reflect larger threats to public safety?
Any factors underlying these questions will help in assessing the likelihood that a hazard
may exist, taking into consideration all potentially valid scenarios. The determination of
likelihood can then be used to assist in determining safety risk probability.
Based on these considerations, the likelihood of an event occurring can be assessed, as:
2.3.3 Safety Risk Severity
Having determined the probability of occurrence, the nature of the adverse consequences
if the event does occur must be assessed. The potential consequences govern the degree
of urgency attached to the safety action required. If there is significant risk of catastrophic
consequences, or if the risk of serious injury, property or environmental damage is high,
urgent follow-up action is warranted. In assessing the severity of the consequences of
occurrence, the following types of questions apply:
• How many lives are at risk (employees, passengers, etc)?
CHAPTER 2 P: 2-14
• What is the likely extent of property or financial damage (direct property loss to the
Company, third party collateral damage, etc)?
• What is the likely media interest?
Risk severity table
2.3.4 Safety Risk Tolerability
Once the safety risk of the consequences of an unsafe event or condition has been
assessed in terms of probability and severity, the third step in the process of bringing the
safety risks of the consequences of the unsafe event or condition under organizational
control is the assessment of the tolerability of the consequences of the hazard if its
damaging potential materializes during operations aimed at delivery of services. This is
known as assessing safety risk tolerability.
This is a two-step process. First, assessment of the safety risk is achieved by combining
the safety risk probability and safety risk severity tables into a safety risk assessment
matrix. Second, the safety risk index obtained from the safety risk assessment matrix must
then be exported to a safety risk tolerability matrix that describes the tolerability criteria.

CHAPTER 2 P: 2-15
The Company must:

• Allocate resources to reduce the exposure to the consequences of the hazards:
• Allocate resources to reduce the magnitude or the damaging potential of the
consequences of the hazards: or
• Cancel the operation if mitigation is not possible.
Safety risk is defined as the assessment, expressed in terms of predicted probability and
severity, of the consequences of a hazard, taking as reference the worst foreseeable
situation. Criteria of standards are required to define acceptable and unacceptable risks.
The matrix is used to prioritize actions to mitigate risk. Having used a risk matrix to assign
values to risks, a range of values may be assigned in order to categorize risks.
Safety risks are categorized as:

• Acceptable;
• Tolerable;
• Intolerable.
The safety risk probability and severity assessment process can be used to derive a safety
risk index. The index created through the methodology described previously consists of an
alphanumeric designator, indicating the combined results of the probability and severity
assessments. For example, consider a situation where a safety risk probability has been
assessed as occasional (4), and safety risk severity has been assessed as hazardous (B).
The composite of probability and severity (4B) is the safety risk index of the consequence.
Risk Severity
Risk Probability
Catastrophic Hazardous Major Minor Negligible
A B C D E
Frequent 5 5A 5B 5C 5D 5E
Occasional 4 4A 4B 4C 4D 4E
Remote 3 3A 3B 3C 3D 3E
Improbable 2 2A 2B 2C 2D 2E
Extremely
1 1A 1B 1C 1D 1E
Improbable
Safety risk assessment matrix
Acceptable (green) means that no further action needs to be taken (unless the risk can be
reduced further at little cost or effort).

CHAPTER 2 P: 2-16
Tolerable (yellow) means that the affected operations can be performed with the risk in
order to have certain benefits, in the understanding that the risk is being mitigated. Cost-
benefit analysis is required.
Unacceptable (red) means that operations under the current conditions must cease until
the risk is reduced to at least the tolerable level.
Safety risks assessed as initially falling in the intolerable region are unacceptable under
any circumstances. The probability and/or severity of the consequences of the hazards are
of such a magnitude, and the damaging potential of the hazard poses such a threat to
safety, that immediate mitigation action is required.
Safety risks assessed in the tolerable region are acceptable provided that appropriate
mitigation strategies are implemented by the Company. A safety risk initially assessed as
intolerable may be mitigated and subsequently moved into the tolerable region provided
that such risks remain controlled by appropriate mitigation strategies. In both cases, a
supplementary cost-benefit analysis may be performed if deemed appropriate.
Cost-benefit or cost-effectiveness analysis is normally an independent process from safety

risk mitigation or assessment. It is commonly associated with a higher level management
protocol, such as a regulatory impact assessment or business expansion project.
However, there may be situations where a risk assessment may be at a sufficiently high
level or have a significant financial impact. In such situations, a supplementary cost-benefit
analysis or cost-effectiveness process to support the risk assessment may be warranted.
This is to ensure that the cost-effectiveness analysis or justification of recommended

CHAPTER 2 P: 2-17
mitigation actions or preventive controls has taken into consideration the associated
financial implications.
Safety risks assessed as initially falling in the acceptable region are acceptable as they
currently stand and require no action to bring or keep the probability and/or severity of the
consequences of hazards under organizational control.

CHAPTER 2 P: 2-18
2.4 SAFETY RISK MITIGATION

2.4.1 General
The objective of safety management is to provide the foundation for a balanced allocation
of resources between all assessed safety risks and those safety risks the control and
mitigation of which are viable.
The risk evaluation forms the basis for deciding on risk control (mitigating) measures and
in assessing the effectiveness of these measures. Risk control measures identify the
consequences associated with both an unacceptable risk and tolerable risk and where
further risk reduction measures are feasible and reasonable.
Identification of possible mitigation is based on the risk description and evaluation,

considering in particular any uncertainties identified and critical assumptions made.
Controls that may eliminate the consequence of a hazard, likelihood-reducing measures
and severity-reducing measures are identified. The measures should address the human
factors (e.g. training and competence), equipment or organisational factors (e.g.
procedures).
There are three generic strategies for safety risk mitigation/risk control:
• Avoidance: The operation or activity is cancelled because safety risks exceed the
benefits of continuing the operation or activity;
• Reduction: The frequency of the operation or activity is reduced, or action taken to
reduce the magnitude of the consequences of the accepted risks;
• Segregation of exposure: Action is taken to isolate the effects of the consequences
of the hazard or build in redundancy to protect against them.
Whenever unacceptable risk levels are identified, mitigations measures (actions) shall be
accounted for. JC Airlines’ SMS should include procedures to prioritize identified hazards
for risk mitigation actions. Systematic and progressive hazard identification and risk
management performance of all aviation safety-related operations, processes, facilities
and equipment, as identified by JC Airlines, should be covered by the Company’s SMS.
Generating the ideas necessary to create suitable risk mitigation measures poses a
challenge. Developing risk mitigation measures frequently requires creativity, ingenuity
and, above all, an open mind to consider all possible solutions. The thinking of those
closest to the problem (usually with the most experience) is often coloured by set ways
and natural biases. Broad participation, including by representatives of the various
stakeholders, tends to help overcome rigid mind-sets. Thinking “outside the box” is
essential to effective problem solving in a complex world. All new ideas should be weighed
carefully before rejecting any of them.

CHAPTER 2 P: 2-19
In evaluating alternatives for risk mitigation, not all have the same potential for reducing
risks. The effectiveness of each option needs to be evaluated before a decision can be
taken. It is important that the full range of possible control measures be considered and
that trade-offs between measures be considered to find an optimal solution. Each
proposed risk mitigation option should be examined from such perspectives as:
• Effectiveness;
• Cost/benefit;
• Practicality;
• Challenge;
• Acceptability;
• Enforceability;
• Durability;
• Residual risks;
• New problems.
Note: “New problems” means what new problems or new (perhaps worse) risks will be
introduced by the proposed change).
Preference should be given to corrective actions that will completely eliminate the risk.
In Safety Risk Mitigation step of Safety Risk Management process the Bow-Tie diagram is
used to evaluate existing and/or to discuss possible additional safety barriers (mitigation
measures). It is understood that additional safety barriers (mitigation measures) might be
found on 3 different levels: technology, procedures or training.

CHAPTER 2 P: 2-20
Controlling safety risks is done by placing barriers to prevent certain undesirable events
from happening. A control can be any measure taken that acts against some undesirable
force or intention, in order to maintain a desired state.
In the Bow-Tie methodology there are preventive or proactive barriers (on the left side of
the undesirable event) that prevent the undesirable event from happening. There are also
corrective or reactive mitigation measures (on the right side of the undesirable event) that
prevent the undesirable event from resulting into unwanted outcome or reduce the
consequence severity of the outcome.
Bow-Tie safety risk mitigation model
According to ICAO Doc 9859 - Safety Management Manual, the possible approaches to
risk mitigation include:
• Revision of the system design (before system implementation);
• Modification of operational procedures;
• Changes to staffing arrangements; and
• Training of personnel to deal with the hazard.
The first step in the safety risk mitigation/control process is hazard/consequence

identification and safety risk assessment.
Once hazards and consequences have been identified and safety risks assessed, the
effectiveness and efficiency of existing aviation system defences (technology, training and
regulations) relative to the hazards and consequences in question must be evaluated.

CHAPTER 2 P: 2-21
As a consequence of this evaluation, existing defences will be reinforced, new ones

introduced, or both.
The second step in the safety risk mitigation/control process is, therefore, evaluation of the
effectiveness of the existing defences within the aviation system.
Company department postholders are responsible for risk mitigation and ownership of the
residual risk within their department.
A periodic review of existing risk mitigation records should be in place within the
Company’s SMS.
In order to maintain a viable operation there is a balance to be found between production

and protection. The optimum balance therefore between cost and safety reflects the
management of risk to a level that is as low as reasonably practicable within the safety
space.

CHAPTER 2 P: 2-22
The safety space boundaries should be defined by the management and reviewed
continually to ensure that they accurately reflect the current situation.
The final step of the risk management cycle is a review of risk mitigation activities to
ensure that the risk mitigation activity has had the desired effect. This process may
include:
• The setting and monitoring of SPIs;
• Monitoring compliance with the appropriate regulations and standards;
• Further safety investigations such as LOSA.
Example of using hazard related terminology for wrong take-off configuration
2.4.2 Safety Analysis

2.4.2.1 General
Safety data reduction to simple statistics is of no practical use unless meaningful

conclusions or countermeasures are produced. The process of producing conclusions and
or countermeasures is called safety analysis. Safety analysis is the process of organising
facts using specific methods, tools or techniques.
2.4.2.2 Safety Database
In the context of safety analysis, the term “safety database” may include the following type
of data or information which can be used to support safety analysis.
• Accident investigation data;
• Mandatory occurrence report data;
• Voluntary reporting data;

CHAPTER 2 P: 2-23
• Continuing airworthiness reporting data;

• Operational performance monitoring data;
• Safety risk assessment data;
• Data from audit findings/reports;
• Data from safety studies/reviews;
• Safety data from other incident/accident investigations, etc.
2.4.2.3 Bias
Unfortunately not all facts are usable for safety analysis. This is because of bias.
Everyone’s judgment is shaped by personal experience and cultural conditioning. Bias is
the tendency to apply a particular response regardless of the situation. The following are
some of the common biases that can affect the validity of safety analyses:
• Frequency bias;
• Selectivity bias;
• Familiarity bias;
• Conformity bias;
• Committee conformity bias;
• Overconfidence bias.
Frequency Bias: Individuals tend to over/under estimate the probability of occurrence of a

particular event because our evaluation is based solely on our personal experience and
conditioning.
Selectivity Bias: Our personal preferences may cause us to select items based on a
restricted core of facts. We have a tendency to ignore those facts that don’t fit the mental
pattern we expect. We may focus on the more obvious facts for example, loud noise,
bright light, most recent event and ignore cues as the more subtle facts that can provide
relevant information about the nature of the event.
Familiarity Bias: In any given situation we tend to choose the most familiar solutions or
patterns. We tend to do things in accordance with patterns of our previous experience,
even if they are not the best solutions for the current situation. For example we may drive
to work using the same route every day even though there may be a shorter route
available.
Conformity Bias: We have a tendency to look for a solution that fit our decision rather than
look for solutions that contradict it. As the strength of our mental model grows we are
reluctant to accept facts that do not fit that mental model that we already know.
Committee Conformity Bias: Most of us have a tendency to fall into line with the majority
view. We do not want to break the Committee’s harmony by disagreeing.

CHAPTER 2 P: 2-24
Overconfidence Bias: There is a tendency to overestimate the extent of our knowledge of

a situation and the likely outcome. The result is we tend to ignore the facts that we don’t
accept as valid, even if in fact they are.
2.4.2.4 Analytical Methods and Tools
The following are the safety analytical tools and methods being used in JC Airlines when
conducting safety analysis:
• Statistical analysis;
• Trend analysis;
• Normative comparisons;
• Simulation and testing;
• Expert panel;
• Cost-benefit analysis.
Statistical analysis: This method can be used to assess the significance of perceived
safety trends often depicted in graphical presentations of analysis results. While statistical
analysis may yield powerful information regarding the significance of certain trends, data
quality and analytical methods must be carefully considered to avoid reaching erroneous
conclusions. Safety Manager shall maintain a safety analytical database of Company,
regional and international accident and incident statistical data. This database can be used
to identify trends, set priorities and produce convincing arguments for countermeasure
creation and implementation. Sources such as ICAO/IATA/FSF safety data bases can be
used.
Trend analysis: By monitoring trends in safety data, predictions may be made about future
events. Trends may be indicative of emerging hazards. By placing upper and lower limits
on trends trend analysis can be used to trigger action such as safety briefings to crew,
modifications to training programs or reward programs for above average safety
performance., when these limits are reached (trigger point).
Normative comparisons: Normative comparisons use normal everyday operational data as

a normal benchmark by which to compare non-normal events. Programs such as LOSA
can be used to show where airline crew fit in comparison to other similar airlines. LOSA
type programs can be created in house as well as using imported programs. Sufficient
data may not be available to provide a factual basis against which to compare the
circumstances of potential events. In such cases, it may be necessary to sample real-
world experience under similar operating conditions.
Simulation and testing: Some investigations may lead to the suggestion of a change in
SOPs for example. Before these countermeasures (SOP changes) are made they may
need to be tested in the simulator using actual line crew.

CHAPTER 2 P: 2-25
Expert panel: The views of peers and specialists can be useful in evaluating the diverse
nature of hazards related to a particular unsafe condition. A multidisciplinary team formed
to evaluate evidence of an unsafe condition can assist in identifying the best course of
corrective action.
Cost-benefit analysis: The acceptance of recommended safety risk control measures

(countermeasures) may be dependent on credible cost-benefit analysis. The costs of
implementing the proposed measures are weighed against the expected benefits over
time. Cost-benefit analysis may suggest that accepting the consequences of the safety risk
is tolerable considering the time, effort and cost necessary to implement corrective action.

CHAPTER 2 P: 2-26
Intentionally Blank

CHAPTER 3 P: 3-1
SAFETY ASSURANCE Rev. 00, 10 JAN 2017
3 SAFETY ASSURANCE
3.1 GENERAL
The two core operational activities of Safety Management System (SMS) are:
• Safety Risk Management,
• Safety Assurance.
The subtleties of the relationship between Safety Risk Management and Safety Assurance
are frequently a source of confusion.
Safety Risk Management must be considered as an early system design activity, aimed at
initial identification of hazards and assessment of safety risks. Safety risk controls are
developed to mitigate risk, and once they are determined to be capable of bringing the
safety risk to ALARP, they are employed in daily operations.
The Safety Assurance function takes over at this point to ensure that the safety risk
controls are being practised as intended and that they continue to achieve their intended
objectives. The safety assurance function also provides for the identification of the need
for new safety risk controls because of changes in the operational environment.
Safety assurance consists of processes and activities undertaken by the Company to

determine whether the SMS is operating according to expectations and requirements. JC
Airlines continually monitors its internal processes as well as its operating environment to
detect changes or deviations that may introduce emerging safety risks or the degradation
of existing risk controls. Such changes or deviations may then be addressed together with
the safety risk management process. The safety assurance process complements that of
quality assurance, with each having requirements for analysis, documentation, auditing
and management reviews to assure that certain performance criteria are met. While quality
assurance typically focuses on the organisation’s compliance with regulatory
requirements, safety assurance specifically monitors the effectiveness of safety risk
controls.
The complementary relationship between safety assurance and quality assurance allows
for the integration of certain supporting processes. Such integration can serve to achieve
synergies to assure that the service provider’s safety, quality and commercial objectives
are met.
Hazard identification is a one-time activity that is conducted either during system design or
when facing significant changes to the original system. Safety assurance is a daily activity
that is conducted non-stop to ensure that the operations that support the delivery of
services are properly protected against hazards. Hazard identification provides the initial
frame of reference against which assurance of safety is conducted on a daily basis.

CHAPTER 3 P: 3-2
These two core operational activities take place under the umbrella provided by safety
policy and objectives and are supported by safety promotion. These two components of an
SMS encompass the necessary organizational arrangements without which hazard
identification and safety risk management would be impossible, or seriously flawed. It can
therefore be considered that safety risk management and safety assurance are the actual
“doing” of SMS; they are the operational activities underlying a performing SMS. Safety
policies and objectives and safety promotion, on the other hand, provide the frame of
reference as well as the support that allow the operational activities underlying safety risk
management and safety assurance to be effectively conducted.
Safety Risk Management and Safety Assurance are supported by a range of safety tools
such as safety reports, audits, investigations, safety performance indicators and flight data
monitoring (FDM). These form a multilayered, proactive and reactive monitoring approach.
This safety information is collated, classified and supported by statistical and data-mining
analysis. The processed safety signals can then be filtered to enable limited investigation
resources to be directed to risk analysis and trend monitoring of these safety signals. The
investigations will determine root causes and contributing factors to make
recommendations to mitigate the risks. Risk reduction occurs in conjunction with
Accountable Management who decides, from risk treatment options, measures to be put in
place to mitigate identified risk as detected by the sensory network. The focus of the SMS
is to maintain airline operational readiness to meet risk and change as well as supporting
continuous improvement.
Safety assurance activities should include the development and implementation of

corrective actions in response to findings of systemic deficiencies having a potential safety
impact. Organizational responsibility for the development and implementation of corrective
actions should reside with the departments cited in the findings.
Safety risk management requires feedback on safety performance to complete the safety
management cycle. Through monitoring and feedback, SMS performance can be
evaluated and any necessary changes to the affected system introduced. Safety
assurance consists of processes and activities undertaken by the Company to provide
confidence as to the performance and effectiveness of the controls.

CHAPTER 3 P: 3-3
3.2 SAFETY PERFORMANCE MONITORING AND MEASUREMENT

3.2.1 General
Safety Performance Monitoring activities are an essential part of the Safety Management
System (SMS). It is the process by which the safety performance of the organisation is
verified in comparison to the agreed safety policies and objectives.
Safety performance measurement of SMS includes the definition of safety performance

indicators, safety performance targets and action plans. The primary task of safety
assurance is control. This is achieved through safety performance monitoring and
measurement, the process by which the safety performance of the Company is verified in
comparison with the safety policy and approved safety objectives. The definition of a set of
measurable performance outcomes also allows identifying where action may be required
to bring operational performance of the system to the level of design expectations. Thus,
measurable performance outcomes permit the actual performance of activities critical to
safety to be assessed against existing organizational controls, so that safety risks can be
maintained ALARP and necessary corrective action taken.
The selection of appropriate safety indicators is the key to the development of ALoS. The
selection of indicators representing low-level/low-consequence system outcomes and
lower- level system functions is required.
Action plans include the operational procedures, technology, systems and programmes to
which measures of reliability, availability, performance and/or accuracy can be specified.
Safety performance measurement is a non-stop activity, involving continuous monitoring

and measurement, by an organization, of selected operational activities that are necessary
to deliver the services the Company was constituted to deliver.
Safety Assurance Monitoring incorporates feedback from the following:

• Safety investigations;
• Safety reports;
• Setting and measurement of safety performance indicators and boundaries;
• Safety audits;
• Safety reviews;
• Review of the SMS.
An SMS allows operators to integrate their diverse safety activities into a coherent system.
Examples of safety activities that are integrated into Company’s SMS include:
a) Occurrence reporting;
b) Flight Data Monitoring (FDM);
c) Line Operations Safety Audit (LOSA);
d) Cabin safety.
CHAPTER 3 P: 3-4
Information used to measure the organization’s safety performance is generated through

its safety reporting systems.
There are two types of reporting systems:

• Mandatory incident reporting systems;
• Voluntary incident reporting systems.
Mandatory incident reporting system requires the reporting of certain types of events (e.g.
serious incidents, runway incursions). This necessitates implementation of detailed
regulations identifying the reporting criteria and scope of reportable occurrences.
Mandatory reporting system tends to collect more information related to high-consequence
technical failures than other aspects of operational activities.
Voluntary reporting system allows for the submission of information related to observed
hazards or inadvertent errors without an associated legal or administrative requirement to
do so. Enforcement action may be waived for reports of inadvertent errors or unintentional
violations. Under these circumstances, reported information should be used solely to
support the enhancement of safety. Such system is considered non-punitive because it
affords protection to reporters thereby ensuring the continued availability of such
information to support continuous improvements in safety performance. The intent is to
promote an effective reporting culture and proactive identification of potential safety
deficiencies.
3.2.2 Safety Performance Indicators
Safety performance indicators are generally data based expressions of the frequency of
occurrence of some events, incidents or reports. The indicator(s) chosen should
correspond to the relevant safety objectives.
Safety performance monitoring is the process by which safety performance indicators

and/or targets of the organization are reviewed in relation to safety policy and objectives.
Such monitoring would normally be done at the SRC and/or SAG level. Any significant
abnormal trend or breach of safety benchmark level would warrant appropriate
investigation into potential hazards or risks associated with such deviation.
Safety Performance Indicators (SPIs) are metrics used to express the level of safety
performance achieved in a system. They provide both safety assurance and hazard
warning.
Safety Performance Measurement is provided by means of Safety Performance Indicators

(SPI) and other objective statistically elaborated reviews, surveys, reports etc.
SPIs traditionally illustrate historic safety achievements by providing a “snapshot” of past

events. Presented either numerically or graphically, they provide a simple, easily
understood indication of the level of safety in a given aviation sector in terms of the
CHAPTER 3 P: 3-5
number or rate of accidents, incidents or casualties over a given time frame. At the highest
level, this could be the number of fatal accidents per year over the past ten years. At a
lower (more specific) level, the safety performance indicators might include such factors as
the rate of specific events (e.g. losses of separation, engine shutdowns, inadvertent slide
deployments, and incorrect step removal procedures). All aspects of the operation should
be covered by SPIs.
SPI statistics can be focused on specific areas of the operation to monitor safety
achievement, or on identifying areas of interest. This “retrospective” approach is useful in
trend analysis, hazard identification, risk assessment, as well as in the choice of risk
control measures.
Safety performance target level setting define the required level of safety performance of a
system. A safety performance target level comprises one or more safety performance
indicators, together with desired outcomes expressed in terms of those indicators.
Sometimes referred as goals or objectives, the safety performance target levels are
determined during the planning phase. They are set so as to ensure the achievement of
the acceptable level of safety considered desirable and realistic for the individual
operator/service provider. The desired safety outcome (target level) may be presented
either in absolute or relative terms. An example of desirable safety outcome,
communicated in absolute terms is: less than 1 fatal accident per 1 000 000 operating
hours.
As a rule, better insight into the acceptable level of safety will be provided by wider range
of different safety performance target levels (and indicators), rather than the usage of a
single one.
The relationship between acceptable level of safety, safety performance target levels and
safety performance indicators, and safety requirements is as follows: acceptable level of
safety is the overarching concept; safety performance target levels are the quantified
objectives pertinent to the acceptable level of safety; safety performance indicators are the
measures/metrics used to determine if the acceptable level of safety has been achieved.
Safety performance monitoring is the process by which safety performance indicators

and/or targets of the organization are reviewed in relation to safety policy and objectives.
Such monitoring would normally be done at the SRC and/or SAG level. Any significant
abnormal trend or breach of safety benchmark level would warrant appropriate
investigation into potential hazards or risks associated with such deviation.
Safety performance target levels are subject to a periodic review and update, as
necessary. These reviews are carried out as part of the strategic safety planning and
improvement activities of the operator/service provider.

CHAPTER 3 P: 3-6
The following are possible safety performance indicators (SPIs) that could be observed:
• System defect which adversely affects the handling characteristics of the aircraft or
renders it unfit to fly;
• In-flight engine shutdown;
• Fire or smoke warning;
• Safety equipment or procedures are defective or inadequate;
• Operating procedures or manual deficiencies;
• Incorrect loading of fuel, cargo, or dangerous goods, or significant weight & balance
error;
• Ground, aircraft, or property damage incident;
• Rejected take-off is executed above 72 kts;
• Runway incursion;
• Runway or taxiway excursion; if any part of the aircraft leaves paved surface during
taxi, take-off, or landing;
• Significant aircraft handling difficulties are experienced;
• Navigation error, involving significant deviation from the intended track;
• Altitude error of more than 300 feet;
• Exceedance of the limiting parameters for the aircraft configuration;
• Communications failure or impairment;
• Unstabilized approach at 1000 feet height;
• Go-around (below 1,000 feet) or windshear go-around from any altitude;
• Flight diversion or return to departure airport, or landing on wrong runway;
• Hard or overweight landing;
• Serious loss of braking;
• Aircraft is evacuated;
• Aircraft lands with reserve fuel or less;
• Near miss, ATC incident, or wake turbulence encounter;
• TCAS RA or GPWS warning incident;
• Significant turbulence, windshear, or other severe weather (including lightning
strikes) is encountered;
• Serious illness, incapacitation, injury, or death of crew member or passenger;
Emergency medical kit is used or contact with infectious substance/disease made;
• Removal of violent, armed, or intoxicated passenger;
• Drugs or alcohol used by crew member on duty;
• Lavatory smoke detectors activated or vandalized;
• Acts of aggression (i.e. bomb threat or hijack) or breach of security procedures;
• Bird strike or foreign object damage;
• Any event where safety standards are significantly reduced;
• Any event which may provide useful information for the enhancement of safety.

CHAPTER 3 P: 3-7
List of JC Airlines flight operations safety performance indicators (SPIs):
SPI name Source SPI definition
FDM Number of unstabilized approaches below 1000 ft per 100

Unstable approaches
ASR flight cycles
FDM Number of in-flight engine shut downs per 1000 flight
In-flight shut downs
ASR hours
FDM Number of configuration error and/or computation of wrong
Configuration errors
ASR data for take-off or landing per 100 flight cycles
ASR Number of high speed rejected take-offs (>72kts) per 100
Rejected take-offs
FDM flight cycles
FDM Number of altitude deviations by more than 300 feet per
Altitude busts
ASR 1000 flight hours
FDM Number of hard landings (high vertical accelerations - g
Hard landings
ASR load 2,0 or more) per 100 flight cycles
ASR
(E)GPWS Number of (E)GPWS warnings per 100 flight cycles
FDM
TCAS RA ASR Number of TCAS RAs per 1000 flight hours
FDM
Overweight landings Number of overweight landings per 100 flight cycles
ASR
Runway incursions ASR Number of runway incursions per 100 flight cycles
Runway excursions ASR Number of runway excursions per 100 flight cycles
Bird strikes ASR Number of confirmed bird strikes per 100 flight cycles
Accidents ASR Number of accidents per 100 flight cycles
Serious incidents ASR Number of serious incidents per 100 flight cycles
Number of incidents with unruly passengers per 100 flight

Unruly passengers ASR
cycles
Dangerous goods Number of dangerous goods spillage, leakage and/or
DGOR
occurrences improper handling per 100 flight cycles
Duty time limitation Number of duty time limitation exceedances per
ASR
exceedances month/year and trends
Number of ground occurrences within apron and taxiways
Ground handling related GDR
that could result in damage to aircraft/equipment or injuries
safety reports ASR
to personnel per 100 flight cycles
CHAPTER 3 P: 3-8
Aircraft returns from flight Number of aircraft returns due to technical failures per 100
ASR
due to technical reasons flight cycles
Number of cases where fuel quantity required the
Fuel emergencies ASR
declaration of an emergency per 100 fight cycles
Number of pilot and/or cabin crew incapacitations per 100
Incapacitations ASR
flight cycles
Number of reported severe turbulence, wind shear, or
ASR other severe weather (including lightning strikes), resulting
Significant weather
FDM in loss of altitude (> 300 ft), injuries, structural damage or
difficulty in controlling the aircraft per 100 flight cycles
Loading or load sheet Number of loading or load sheet errors per 100 flight
ASR
occurrences cycles
Undeclared dangerous Number of undeclared dangerous goods per 100 flight
DGOR
goods cycles
Number of fire and/or smoke events, including those
Fire / smoke events ASR
where the fires were extinguished, per 1000 flight hours
Number of unintentional deviation of airspeed, intended
Navigation errors ASR track or altitude that result in activation of deviation
notification per 100 flight cycles
ASR Number of go-arounds below 1000 ft or windshear go-
Go-arounds
FDM around from any altitude per 100 flight cycles
Number of failures of more than one system in a multiple-
Dual system failures ASR
redundancy system per 1000 flight hours
Note: Under column “Source” the principal data sources are listed.
Safety performance indicators covering the operation in the cabin may be:
• Cabin prepared for an emergency landing;
• A communication system (i.e. pa, video equipment, or call signals) fails or becomes
impaired;
• Decompression of the aircraft;
• A disruptive passenger is confronted;
• Emergency equipment is non-operational or not present;
• An emergency landing;
• Aircraft is evacuated;
• Fire/smoke/fumes are present in the passenger cabin;
• A hazardous material is present in the passenger cabin;
• An intoxicated passenger is confronted;
• A cabin crew jump seat is broken or inoperable;
• An overflow of the lavatory water;

CHAPTER 3 P: 3-9
• A potential hazard which may cause injury to a passengers or cabin crew (i.e. torn
carpet or broken cart);
• A safety related interruption during sterile cockpit;
• Significant turbulence encountered;
• Inadvertent deployment of slide;
• A lavatory smoke detector activated or vandalized;
• A passenger smoking incident;
• Any identified hazards and/or potential risks;
• Any event where safety standards may have been compromised;
• Any event which may provide useful information for the enhancement of cabin
safety.
The Company has established a process of monitoring the performance of SPIs including
remedial action procedure whenever unacceptable or abnormal trends are triggered.
Each Company department (as specified) is obliged to, by using safety occurrence
database, define safety indicators which demonstrate an occurrence or a recurring
condition (e.g. during the period of six months or a year) believed that may consequentially
jeopardize safety. A number of their recurrence during the monitored period represents
safety indicator value.
The objective is that the selected safety indicator value be reduced to a predetermined
number of recurrences - safety target value. Safety target value is achieved by application
of the predetermined action plan during the defined period and by continuous monitoring of
both the implementation thereof and the system performance during such period system
evaluation is conducted.
In the end of such defined period interval it shall be determined whether the defined target
has been accomplished, i.e. whether the action plan has been efficacious and whether in
this manner the system operational performance has been improved. In case that the
value determined as the safety performance target value has not been accomplished it is
necessary to repeat the safety indicator analysis and adopt a new action plan.
Each department, as applicable, is required to define safety indicator value and safety
target value and, along with the analysis and the action plan, deliver it to the Safety
Department. During the determined period of implementation of the action plan following
the defined safety indicator a recurrent report is made on monitoring (an overview) in the
SAG meetings or upon the request of the Safety Department. Control is conducted in
relation to elements of the system, including, hardware, software, special procedures or
procedural steps, and supervisory practices designed to keep operational activities on
track. It is particular important to provide feedback to responsible parties that required
actions are taking place, required outputs are being produced and expected outcomes are
being achieved.

CHAPTER 3 P: 3-10
A competent unit is required to conduct control, i.e. continuous monitoring of a particular

operation, i.e. a part of the system which the action plan is applied to. In addition, the
Safety Department monitors execution of this function (safety audit, safety inspection).
As is with the complete implementation, SMS requires from a competent unit, and in
compliance with the JC Airlines SMS, obligation and responsibility for the implementation
of this part of Safety Assurance – the postholder.
Setting measurable safety objectives is included in the safety performance monitoring and
measurement element of the Safety Assurance component of the SMS framework. By
setting performance measures, we can be able to track and compare our operational
performance against a target over a period of time.
Safety performance indicators and their associated performance settings should be

developed in line with aviation standard safety settings and in consultation with, and
subject to, the Authority’s (SSCA) agreement.
An ICAO has recommended that State oversight authority establishes an acceptable level
of safety to be achieved by its safety programme that will be expressed by:
• 0.5 fatal accidents per 100.000 hours for airline operators (safety indicator) with a
40 per cent reduction in five years (safety target);
• 50 aircraft incidents per 100.000 hours flown (safety indicator) with a 25 per cent
reduction in three years (safety target);
• 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);
• bird strike per 1.000 aircraft movements (safety indicator) with a 50 per cent
reduction in five years (safety target);
• 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);
• 40 airspace incidents per 100.000 hours flown (safety indicator) with a 30 per cent
reduction over the five-year moving average (safety target).
The above numbers have been used as the basis for JC Airlines’ SMS program (high
consequence) safety indicator values and safety targets.

CHAPTER 3 P: 3-11
Example of Safety Performance Indicators for air operator:
Sample data sheet used to generate a high-consequence SMS Safety Indicator chart:

CHAPTER 3 P: 3-12
The difference of Safety Performance Indicators from a Safety Indicators is that Safety
Performance Indicators quantify the outcome value of a selected low-level consequence
process, whereas Safety Indicators quantify the outcome of a selected high-level
consequence event.
Example of an SMS safety performance indicator chart (with safety alert and safety target
level settings):
Safety alert level setting:

The safety alert level for a new monitoring period (current year) is based on the preceding
period’s performance (preceding year), namely its data points average and standard
deviation. The three alert lines are average + 1 SD (standard deviation), average + 2 SD
(standard deviations) and average + 3 SD (standard deviations).
An alert (abnormal/unacceptable trend) is indicated if any of the conditions below are met
for the current monitoring period (current year):
• Any single point is above the 3 SD line;
• 2 consecutive points are above the 2 SD line;
• 3 consecutive points are above the 1 SD line.
When an alert is triggered (potential high risk or out-of-control situation), appropriate

follow-up action is expected, such as further analysis to determine the source and root
cause of the abnormal incident rate and any necessary action to address the unacceptable
trend.
Safety target level setting (planned improvement):

The target level setting may be less structured than the alert level setting, e.g. target the
new (current year) monitoring period’s average rate to be say 5% lower (better) than the
preceding period’s average value.
Target achievement:
At the end of the current year, based on e.g. 5% improvement target, if the average rate
for the current year is at least 5% or more lower than the preceding year’s average rate,
then the set target of 5% improvement is deemed to have been achieved.

CHAPTER 3 P: 3-13
The rationale for determining the target quantum of a given SPI should be objective. It
should be correlated to the nature and scope of planned or strategic actions that improve
the safety/quality performance of the operational process underlying the SPI.
Safety alert and safety target levels - validity period:

Alert and target levels should be reviewed/reset for each new monitoring period, based on
the equivalent preceding period’s average rate and SD, as applicable.
Safety performance indicators shall be periodically reviewed.
3.2.3 Safety Audits
Safety audits provide a means for systematically assessing how well the business is
meeting its safety objectives and implementing its SMS. The safety audit programme will
provide feedback to senior management concerning the safety performance of the
business.
JC Airlines shall establish and maintain an audit programme and procedures for periodic
SMS audits to be carried out. The objectives of the audit will be to determine the following:
• Whether the SMS has been properly implemented and maintained;
• Whether the activity conforms to planned arrangements for safety risk
management;
• If there is evidence of the SMS principles being met.
Safety auditing is one of JC Airlines’ core safety management activities. Similar to financial
audits, safety audits provide a means for systematically assessing how well the
organization is meeting its safety objectives.
The safety audit program, together with other safety oversight activities (safety
performance monitoring), provides feedback to managers of individual departments and
senior management concerning the safety performance of JC Airlines. This feedback
provides evidence of the level of safety performance being achieved.
Safety auditing is a proactive safety management activity, providing a means of identifying

potential problems before they have an impact on safety.
Safety audits may be conducted internally or by an external safety auditor. Demonstrating

safety performance for State regulatory authorities is the most common form of external
safety audit (regulatory safety audit). Increasingly, however, other stakeholders may
require an independent audit as a precondition to providing a specific approval, such as for
financing, insurance, partnerships with other airlines, and entry into foreign airspace.

CHAPTER 3 P: 3-14
Regardless of the driving force for the audit, the activities and products from both internal
and external audits are similar.
Safety audit includes the observation and analysis of matters such as:
• Management practices;
• Operational policies and procedures;
• Flight operations;
• Safety promotion programmes;
• Safety training;
• Maintenance standards and procedures;
• Quality control;
• Manuals, documentation and other records;
• Support equipment;
• Security.
These audits are carried out by a team of specialists in such fields as flight operations,
safety management and maintenance using the following methods:
• Review of documentation, records and the systems of operation and maintenance
control;
• Observation of facilities, equipment and work practices;
• Interviews with operations, maintenance, supervisory and support staff;
• Review of crew qualifications and the conduct of flights.
Safety auditors may be safety personnel from Safety Department or nominated by Safety
Manager according to their knowledge and experience.
Safety audits should be conducted on a regular and systematic basis (yearly audits).
Critical self-assessment (self-audit) is a tool that JC Airlines management can employ to

measure safety margins. This self-audit checklist is designed for use by senior
management to identify organizational events, policies, procedures or practices that may
be indicative of safety hazards. There is no right or wrong answers in all situations, nor are
all the questions relevant to all types of operations. However, the response to a certain line
of questioning may help reveal JC Airlines safety health.
JC Airlines safety audits are used to ensure that:

• The structure of the SMS is sound in terms of appropriate levels of staff compliance
with approved procedures and instructions, and a satisfactory level of competency
and training to operate equipment and facilities and to maintain their levels of
performance;

CHAPTER 3 P: 3-15
• Effective arrangements exist for promoting safety, monitoring safety performance

and processing safety issues;
• Adequate arrangements exist to handle foreseeable emergencies.
Ideally, internal safety audits should be conducted yearly, following a cycle that ensures
each functional area is audited as a part of the organization’s plan for evaluating overall
safety performance.
Safety audits should entail a periodic detailed review of the safety performance,
procedures and practices of each area with safety responsibilities.
Safety audits should go beyond just checking compliance with regulatory requirements
and conformance with standards. The audit team should assess whether the procedures in
use are appropriate and whether there are any work practices that could have unforeseen
safety consequences.
All audits should be pre-planned and supporting documentation (usually in the form of
checklists) of the audit content prepared. Among the first steps in planning an audit will be
to verify the feasibility of the proposed schedule and to identify the information that will be
needed before commencement of the audit. It will also be necessary to specify the criteria
against which the audit will be conducted and to develop a detailed audit plan together
with checklists to be used during the audit.
For an audit to be successful, the cooperation of the personnel of area concerned is

essential. The safety audit program should be based on the following principles:
• It shall never appear to be a “witch hunt”. The objective is to gain knowledge. Any
suggestions of blame or punishment will be counterproductive;
• The audits should make all relevant documentation available to the auditors and
arrange for staff to be available for interview as required;
• Facts should be examined in an objective manner;
• A written audit report describing the findings and recommendations should be
presented to the area within one month;
• The staff as well as the management should be provided with feedback concerning
the findings of the audit;
• Positive feedback should be provided by highlighting in the report the good points
observed during the audit. While deficiencies must be identified, negative criticism
should be avoided as much as possible;
• The need to develop a plan to resolve deficiencies should be required.
Following an audit, a monitoring mechanism may be implemented to verify the

effectiveness of any necessary corrective actions. Follow-up audits should concentrate on
aspects of the operations where the need for corrective action was identified. Audits to
follow up previous safety audits where corrective action was proposed or because an

CHAPTER 3 P: 3-16
undesirable trend in safety performance was identified cannot always be scheduled in

advance.
The safety audit process:
Internal SMS audits should be scheduled and notified well in advance.
Internal SMS audits may include:

• Visits to one or more operating sites;
• Interviews with postholders, managers and operational staff within and outside of
the Company;
• Document reviews (e.g. for completeness, currency and appropriateness);
• An evaluation of the safety management tools being employed by the Company.
An internal auditing plan should be performed to check all the Company‘s Safety
Management System and to keep it continuously up to date in respect of the management
of change. The internal SMS audit plan should:
• Include the sampling of completed/existing safety risk assessments;
• Include the sampling of safety performance indicators for data currency and their
target/alert settings performance;
• Cover the SMS interface with sub-contractors.
Internal SMS audits will be conducted in a repeatedly consistent manner using the
following pattern:
• Audit preparation (notification, documentation, protocols and checklists, planning,
etc.);
• Brief personnel before commencing;
• Perform audit;
• Validate the findings (if needed with the help of a subject expert);
• Brief personnel after the audit;
CHAPTER 3 P: 3-17
• Prepare an audit report;

• Report to management;
• Add findings in the hazard tracking system;
• Follow-up on open items.
Every hazard tracked during an audit will be analysed through the risk management
process.
Where appropriate, internal SMS audit/assessment reports shall be submitted or

highlighted for the Accountable Manager’s attention and review.
In conducting an internal SMS (or safety) audit the audit team should follow the following
audit principles:
• Transparency and disclosure;
• Timeliness;
• Systematic, consistent and objective;
• Fairness;
• Quality.
The philosophy of “no secrets” is very important during the internal SMS audit and in the
reporting process. By openly discussing concerns or apparent shortcoming, as soon as
they are identified, the auditor will provide the convening manager with the opportunity to
provide additional information or in some cases take immediate action to resolve the issue.
Audit results including all identified nonconformities and findings, will be provided to the
convening manager at the end of the audit through a verbal debriefing and subsequent
provision of a written report. The written report must be consistent with the verbal
debriefing.
The audit report will be produced and provided by the auditor to the convening manager
on a timely basis.
Internal SMS audits will be conducted in a systematic, consistent and objective manner.
There should be no variation in the scope, depth and quality of the audits from that which
was agreed between the auditor and/or audit team and the convening manager. However,
it must be recognized that the depth of investigation may have to be modified during the
course of the audit in order that the auditor can accurately identify the cause(s) of non-
conformities.
Audits should to be conducted in a manner such that operator personnel involved in the
audit are given every opportunity to monitor, comment and respond. As previously noted
such opportunities should be provided as soon as a non-conformity is identified or
suspected.

CHAPTER 3 P: 3-18
3.2.4 Safety Reviews
Safety reviews are conducted during introduction and deployment of new technologies,
change or implementation of procedures, or in situations of a structural change in
operations. Safety reviews are a fundamental component of the management of change.
They have a clearly defined objective that is linked to the change under consideration.
Safety reviews are conducted by the Safety Department, which looks for effective
performance of the following safety management activities under the proposed changes:
• Hazard identification and safety risk assessment/mitigation;
• Safety measurement;
• Management accountabilities;
• Operational personnel skills;
• Technical systems;
• Abnormal operation.
3.2.5 Safety Surveys
Safety surveys of JC Airlines operations and facilities can provide management with an
indication of the levels of safety and efficiency. Understanding the systemic hazards and
inherent risks associated with everyday activities allows JC Airlines to minimize unsafe
acts and respond proactively by improving the processes, conditions and other systemic
issues that lead to unsafe acts. Safety surveys are one way to systematically examine
particular elements or the processes used to perform a specific operation - either generally
or from a particular safety perspective. They are particularly useful in assessing attitudes
of selected populations, e.g. line pilots for a particular aircraft type.
Safety surveys examine particular elements or procedures of a specific operation, such as

problem areas or bottlenecks in daily operations, perceptions and opinions of operational
personnel and areas of dissent or confusion.
Safety surveys are usually independent of routine inspections by government or Company

management. Surveys completed by operational personnel can provide important
diagnostic information about daily operations and significant information regarding many
aspects of the organization, including:
• Perceptions and opinions of operational personnel;
• Level of teamwork and cooperation among various employee groups;
• Problem areas or bottlenecks in daily operations;
• Safety culture;
• Current areas of dissent or confusion.

CHAPTER 3 P: 3-19
Safety surveys may involve the use of:

• Checklists;
• Questionnaires;
• Informal confidentiality reviews.
Surveys may provide an inexpensive source of significant safety information. The validity
of all survey information obtained may need to be verified before corrective action is taken.
Safety surveys can be conducted via e-mail or by other means under the discretion of the
Safety Manager.
3.2.6 Safety Investigations
Every event, including each reported incident/accident, should be investigated. The extent
of the investigation will depend on the actual and potential consequences of the
occurrence or hazard. This can be determined through a risk assessment. Reports that
demonstrate a high potential shall be investigated in greater depth than those with low
potential. The investigative process shall be comprehensive and should attempt to address
the factors that contributed to the event, rather than simply focusing on the event itself -
the active failure. Active failures are the actions that took place immediately prior to the
event and have a direct impact on the safety of the system because of the immediacy of
their adverse effects. They are not, however, the root cause of the event; as such,
applying corrective actions to these issues may not address the real cause of the problem.
A more detailed analysis is required to establish the organizational factors that contributed
to the error. The investigator, or team of investigators must be technically competent and
either possess or have access to background information, so the facts and events are
interpreted accurately. The investigator shall have the confidence of the staff and the
investigation process shall be a search to understand how the mishap happened, not a
hunt for someone to blame.
An initial risk assessment assists in determining the extent of the full investigation. The
investigation and analysis will include the following:
• Determination of “what” and “why” the event happened, rather than, “who’s” to
blame;
• Ensure that the authorities are appropriately notified;
• Immediate causal and contributing factors;
• Organizational factors that may contribute to the hazard or incident;
• The unsafe acts of the operators;
• A report which will implement recommendations.
Any hazards/threats identified or uncovered during incident/accident investigation

processes shall be appropriately accounted for and integrated into the JC Airlines’ SMS
hazard collection and risk mitigation procedure.
CHAPTER 3 P: 3-20
3.2.7 Flight Data Monitoring (FDM)

3.2.7.1 General
Flight Data Monitoring (FDM), sometimes referred to as Flight Data Analysis (FDA), or
Flight Operations Quality Assurance (FOQA) provides another tool for the proactive
identification of hazards. FDM is a logical complement to hazard and incident reporting
and to LOSA.
Flight Data Monitoring (FDM) in JC Airlines is the systematic, pro-active and non-punitive
use of recorded flight data from routine flight operations with the aim of improving safety.
The main objective of the FDM is to use recorded flight data to detect technical flaws,
unsafe practices, or conditions outside of desired operating procedures early enough to
allow timely intervention to avert accidents or incidents and to identify trends which could
lead to hazardous operational consequences with the ultimate goal of enhancing flight
safety. The most effective means of achieving this goal is through pilot education and
training.
Flight data monitoring is used as part of JC Airlines’ Safety Management System to

identify deviations from SOPs or areas of risk and measure current safety margins. This
will establish a baseline operational measure against which to detect and measure any
change. FDM system should enable the user to determine where non-standard, unusual or
basically unsafe circumstances occur in operations.
The FDM core function is to monitor and report on operational risk. Areas of risk are
highlighted via a continuous reporting loop. This reporting loop has been established to
enable effective feedback, corrective action and continual monitoring of remedial action
taken. JC Airlines FDM policy is strictly non-punitive. It is focused on improving safety.
Recorded flight data shall not be used for any disciplinary purposes. A strict confidentiality
agreement has been established between the pilots and the Company.
Flight data monitoring is used to detect flight parameter exceedances and to identify
nonstandard or deficient procedures, weaknesses in the ATC system, and anomalies in
aircraft performance. FDM allows the monitoring of various aspects of the flight profile,
such as the adherence to the prescribed take-off, climb, cruise, descent, approach and
landing SOPs. Specific aspects of flight operations can be examined either retrospectively
to identify problem areas, or proactively prior to introducing operational change and
subsequently, to confirm the effectiveness of the change.
During incident analysis, flight recorder data for the incident flight can be compared with
the fleet profile data, thereby facilitating analysis of the systemic aspects of an incident. It
may be that the parameters of the incident flight vary only slightly from many other flights,
possibly indicating a requirement for change in operating technique or training. For
example, it would be possible to determine whether a tail-scrape on landing was an
isolated event, or symptomatic of a wider mishandling problem, such as over-flaring on
touchdown or improper thrust management.

CHAPTER 3 P: 3-21
Engine monitoring programmes utilizes the automated analysis of flight recorder data for
reliable trend analysis as manually coded engine data are limited in terms of accuracy,
timeliness and reliability. It is also possible to monitor other aspects of the airframe and
systems.
Objectives of JC Airlines’ Flight Data Monitoring (Flight Data Analysis) Programme are to:
• Identify areas of operational risk and quantify current safety margins;
• Identify and quantify changing operational risks by highlighting when nonstandard,
unusual or unsafe circumstances occur;
• Use the FDM information on the frequency of occurrence, combined with an
estimation of the level of severity, to assess the risks and to determine which may
become unacceptable if the discovered trend continues;
• To put in place appropriate risk mitigation techniques to provide remedial action
once an unacceptable risk, either actually present or predicted by trending, has
been identified;
• Confirm the effectiveness of any remedial action by continued analysis.
Confirmation of the effectiveness of any remedial action by continued analysis:
In summary, FDM offers a wide spectrum of applications for safety management, as well
as improvements in operational efficiency and economy. Data aggregated from many
flights are useful to help:
• Determine day-to-day operating norms;
• Identify unsafe trends;
• Identify hazards in operating procedures, fleets, airports, ATC procedures, etc.;
• Monitor the effectiveness of specific safety actions taken;
• Reduce operating and maintenance costs;
• Optimize training procedures;
• Provide a performance measurement tool for risk management programmes.

CHAPTER 3 P: 3-22
Typically, FDM data are being used for:

• Exceedance detection;
• Routine measurements;
• Incident investigations;
• Continuing airworthiness;
• Linked databases (or integrated safety analysis).
FDM programme outline – information flow:
Flight Data Monitoring (FDM) is used for detecting exceedances or safety events, such as
deviations from flight manual limits, SOPs, or good airmanship. A set of core events
(provided by the FDM software vendor in consultation with the Company) establishes the
main areas of interest to the Company. Examples: High lift-off rotation rate, stall warning,
GPWS warning, flap limit speed exceedance, fast approach, high/low on glide slope, and
heavy landing. FDM parameters shall be harmonised with the Company’s published
stabilised approach parameters and consistent with the Company’s published SOPs.

CHAPTER 3 P: 3-23
FDM process model:
FDM provides useful information which can complement that provided in crew reports.
Examples: Reduced flap landing, emergency descent, engine failure, rejected take-off, go-
around, TCAS or GPWS warning, and system malfunctions.
Data are retained from most flights, not just the ones producing significant events. A
selection of parameters is retained that is sufficient to characterize each flight and allow a
comparative analysis of a wide range of operational variability. Trends will be identified
before there are statistically significant numbers of events. Emerging trends and
tendencies are monitored before the trigger levels associated with exceedances are
reached.
CHAPTER 3 P: 3-24
Examples of parameters monitored are take-off weight, flap setting, rotation and lift-off
speeds versus scheduled speeds, maximum pitch rate and attitude during rotation, gear
retraction speeds, heights and times.
Examples of comparative analyses are pitch rates from high versus low take-off weights,
good versus bad weather approaches and touchdowns on short versus long runways.
Recorded data provide valuable information for follow-up to mandatory reportable

incidents and other technical reports. Quantifiable recorded data have been useful in
adding to the impressions and information recalled by the flight crew. The recorded data
also provide an accurate indication of system status and performance, which may help in
determining cause and effect relationships.
Examples of incidents where recorded data could be useful:

a) Emergencies, such as:
• High-speed rejected take-offs;
• Flight control problems;
• System failures;
b) High cockpit workload conditions as corroborated by such indicators as:
• Late descent;
• Late localizer and/or glide slope interception;
• Large heading change below a specific height;
• Late landing configuration;
c) Unstabilized and rushed approaches, glide path excursions, etc.;
d) Exceedances of prescribed operating limitations (such as flap limit speeds, engine
overtemperatures, Vspeeds, and stall onset conditions);
e) Wake vortex encounters, low-level wind shear, turbulence encounters or other
vertical accelerations.
The integration of all available sources of safety data provides the company SMS with
viable information on the overall safety health of the operation. For example, a flap over-
speed should result in:
• Crew report;
• FDM event;
• An engineering report.
The crew report provides the context, the FDM event provides the quantitative description
and the engineering report provides the result.
FDM system have proven to be very effective in reminding crews to submit reports during
the early stages and are then a useful audit tool, confirming reporting standards in an
established programme.
CHAPTER 3 P: 3-25
3.2.7.2 FDM Programme
The objective of a FDM programme is to use flight data to detect technical flaws (on
request), unsafe practices, or conditions outside of desired operating procedures early
enough to allow timely intervention to avert accidents or incidents. FDM programme
involves equipping company aeroplanes with specialised devices which continuously
record up to hundreds of different flight-data parameters from aircraft systems and
sensors, analysing the data, identifying trends, and taking action to correct problems. The
analysis of flight data reconstructing entire flight on the basis of the values over time of
flight-data parameters such as heading, altitude, thrust settings, ground speed and many
others. FDM involves capturing and analysing flight data to determine if the pilot, the
aeroplane’s systems, or the aeroplane itself deviated from typical operating norms. All
aircraft fleets, used in JC Airlines’ operations, shall be included in FDM program.
Safety Manager bears the main responsibility for Flight Data Monitoring system and
analysis activities.
FDM involves systems that capture flight data, transform the data into an appropriate
format for analysis, and generate reports and visualization to assist in assessing the data.
Basic equipment required to support Flight Data Monitoring Programme includes:
• A flight data recorder (FDR, QAR or equivalent);
• A data retrieval device which may be an optical disc/PC card or a wireless QAR that
automatically transmits the encrypted data through a ground link to the ground
station;
• A ground station (usually a desk top computer loaded with the appropriate
software), to analyse the data and identify deviations from expected performance;
• Optional software for flight animation facilitating a visual simulation of actual flight
events.
Running of the FDM programme may be contracted out to a third party, thus removing the
data handling and basic analysis tasks. However, sufficient expertise must remain within
JC Airlines to control, assess and act upon the processed information received back from
the other company. Responsibilities for action may not be delegated and JC Airlines still
holds overall responsibility for its FDM programme. This should be clearly stated in any
agreement between JC Airlines and contracted third party.
Modern glass-cockpit and fly-by-wire aircraft are equipped with the necessary digital data
buses from which information can be captured by a recording device for subsequent
analysis. Quick Access Recorders (QARs) are installed in the aircraft and record flight data
onto a low-cost removable medium such as a tape cartridge, optical disk, or solid-state
recording medium. The recording can be removed from the aircraft after a series of flights.
Data are downloaded from the aircraft recording device into a ground-based replay and
analysis systems, where the data are held securely to protect this sensitive information. A
variety of computer platforms, including networked PCs, are capable of hosting the

CHAPTER 3 P: 3-26
software needed to replay the recorded data. The analysis software checks the
downloaded flight data for abnormalities. The exceedance detection software typically
includes a large number of trigger logic expressions derived from a variety of sources such
as flight performance curves, SOPs, engine manufacturers’ performance data, and airfield
layout and approach criteria.
The target of flight data collection process, performed by Maintenance & Engineering
Department, is to collect flight data generated from factual line operation. Maintenance &
Engineering Department has responsibility to establish procedures for collecting and
handing over of flight data. Raw data recorded on FDR/QAR is downloaded and sent by
JC Airlines maintenance personnel to JC Airlines Maintenance & Engineering Department.
Flight data shall be intact, as recorded by QAR, to assure confidentially and accuracy of
information. The data is then delivered to third party contractor (company Sagem), who
converts raw data into engineering units and filters it for deviations from known triggers.
The captured flight data are analysed by a computer system that evaluates predefined
events for deviations from the Company’s specified tolerance thresholds. Converted data
and trigger deviation reports are available on-line through a special programme
(Cassiopée) to authorized users within the Safety Department (Safety Manager, Flight
Safety Officer). Data is assessed for:
• Regular readings;
• On demand readings – for the purpose of an incident/accident investigation.
Deviations of more than certain predetermined values (exceedances) are flagged and
evaluated by the Flight Safety Officer (data quality check, known also as data verification
and validation, is done by Flight Safety Officer). The evaluation of the information
extracted from the flight data needs to be in the context of Company operations and may
require blending flight data results with other information, such as pilot reports, air traffic
control procedures etc. to fully understand the event or statistic. After investigating these
exceedances to determine their validity and analysing them to understand possible
causes, the Flight Safety Officer will propose and evaluate corrective actions. When
required, exceedances may be deliberately aggregated in safe and controlled environment
to check correct FDM system functioning. There are a number of circumstances where
FDM data will indicate that immediate safety action is required and a fast procedure to
ensure safety critical remedial action should be defined. In general, the urgent actions are
associated with continued airworthiness check, rather than operational situations. For
example, a very hard landing with potential damage that has not been reported by other
means will trigger relevant structural checks as soon as possible, whereas flight crew
remedial investigations are not so urgent.
FDM data should normally be obtained and examined within five days after they were
recorded.
The FDM system shall have the ability to restrict access to sensitive data and also control
the ability to edit data. Flight Safety Officer should have full access, while operations

CHAPTER 3 P: 3-27
management may only have oversight of de-identified data and the ability to add their
views and recommendations.
JC Airlines follows a closed-loop process in applying a FDM programme:
a) Baseline established. Initially, the Company has established a baseline of
operational parameters against which changes can be detected and measured;
b) Unusual or unsafe circumstances highlighted. The user determines when non-
standard, unusual or basically unsafe circumstances occur; by comparing them to
the baseline margins of safety, the changes can be quantified. Example: Increases
in unstable approaches (or other unsafe events) at particular locations;
c) Unsafe trends identified. Based on the frequency of occurrence, trends are
identified. Combined with an estimation of the level of severity, the risks are
assessed to determine which may become unacceptable if the trend continues.
Example: A new procedure has resulted in high rates of descent that are nearly
triggering GPWS warnings;
d) Risks mitigated. Once an unacceptable risk has been identified, appropriate risk
mitigation actions are decided and implemented. Example: Having found high rates
of descent, the SOPs are changed to improve aircraft control for optimum/maximum
rates of descent;
e) Effectiveness monitored. Once a remedial action has been put in place, its
effectiveness is monitored, confirming that it has reduced the identified risk and that
the risk has not been transferred elsewhere. Example: Confirm that other safety
measures at the airfield with high rates of descent do not change for the worse after
changes in approach procedures.
JC Airlines is using the following Flight Data Monitoring analysis and visualization
programme: Cassiopée Flight Data Monitoring powered by Analysis Ground Station (AGS)
provided by the Company SAGEM. The purpose of Analysis Ground Station (AGS) is to
provide report generation from automatic and manual data selection for Flight Data
Monitoring, import/export functions, numerous expanded programming capabilities,
advanced analysis and database management features. Cassiopée Flight Data Monitoring
powered by Analysis Ground Station (AGS) is compliant with all current FDM national and
international regulations, including the ones regarding integrity of the system, validity and
reliability of the data.
The Analysis Ground Station (AGS) is a Windows 2000 compatible replay and analysis
system developed by SAGEM and designed for mono-user or multi-user applications. It
can interface with any QARs/FDRs, regardless of the aircraft source. In the operation-
oriented application, AGS has flight operations monitoring with routine detection and
exceedance detection capabilities.
In an automatic analysis AGS can analyse and process all data available from a recorder
in order to provide customized report as requested. AGS has a processing time going from
1 to 5 seconds for a 1 hour recording, depending on the number of parameters available.

CHAPTER 3 P: 3-28
AGS generates an analysis report showing events with classification levels, gives a flight
and event data base update, and shows various trend monitoring processes.
During the manual and on-event analysis, AGS provides an efficient graphic user’s
interface to view quickly all pertinent data for troubleshooting. AGS has preformatted
parameter sets to have quick access to pertinent data including tabular, cockpit animation,
landing graphic representation, and external data file output/input.
Example of graphic presentation:
Example of parameters evolution curves:
The SAGEM AGS has been complemented by a full range of support products to fit all the
user’s needs. For example, the data can be securely dispatched in the airline with the AGS

CHAPTER 3 P: 3-29
Data Viewers. The Flight Safety Officer is able to work and present dynamic statistics with
the AGS Report Viewers, even though he does not run the AGS on his computer.
The AGS is a plug-and-play system. All required components are integrated into the
system, which provides the following:
• Decoding frames for aircraft parameter conversion into engineering units;
• Procedure sets for the customer fleet and flight operations analysis;
• Predefined statistical reports for periodic analysis of fleet activity.
AGS automatically provides data in form of:

• Data files for dedicated interfaces used for further analyses (engine monitoring
systems, etc.);
• Engineering values dedicated for in depth manual analyses of the particular flight
and three dimensional animated flight representation;
• Statistical analyses functions.
During manual flight analyses of engineering values one can compare different flight
parameters in form of tabular, numeric, graph or even generic aircraft instrument
representation. Three dimensional animated representation of the flight is also based on
engineering data. It represents:
• Virtual instrument panel;
• Three dimensional animation scenes;
• Aeroplane trajectory projected on dynamic aviation charts;
• Final approach on dynamic runway plan and profile view.
Cassiopée FDM program provides data analysis for all recorded flights:
• Creation of a dedicated page for each flight;
• Flight information display - flight date & time, take-off/landing airports and runways,
aircraft identification;
• Events detection for abnormal/non-standard situations with additional information;
• 3D Google Earth vision of the actual aircraft path with event markers on flight path;
• Display of most important parameters values during a few minutes around take-off
& landing in the form of tabular data and dynamic curves;
• Weather indication with METAR code available for most airports at take-off and
landing;
• Indication of captain or first officer in control of the aircraft during take-off and
landing phases.
Analysis Ground Station (AGS) Capability/Feature:
Data storage and management:

• Accepts data in multiple formats;

CHAPTER 3 P: 3-30
• Capability to filter and sort events by type, date, aircraft type or other criteria;
• Stores events within context of preceding and succeeding timeframes;
• Easily add fleet types and event and measurement definitions;
• Data de-identification capability;
• Airport/aircraft libraries available;
• Stores raw data (typically de-identified);
• Exports data to external tools.
Monitoring and analysis capabilities:

• Automatic event detection;
• Flight efficiency analysis;
• Performs statistical analysis;
• Provides graphical analysis of flight parameters;
• Identifies trends;
• Provides flight data replay;
• Flight animation capabilities.
Report generation and querying:
• Automated report generation;
• Customized outputs;
• Stores results of queries for future use;
• Exports analysis results to other systems/tools.
System features:
• Operating system requirements – Win 95/98/2000 or above;
• User configurable security – up to 16 user groups with individual access privileges.
Fingerprint recognition on request;
• Capacity – unlimited;
• Supports any fleet size – unlimited;
• Supports multi-user application;
• Help feature available;
• Tutorial available;
• Data encryption.
Support:
• Ongoing development;
• Maintenance support;
• Training provided;
• Help desk;
• Web site;
CHAPTER 3 P: 3-31
• Periodic costumer conference – once a year.
When considering an inoperative QAR or equivalent data system, the associated MEL
conditions are dependent upon the criticality of the uses to which the data is put. While
there are no specific requirements for non-mandatory recorders, if, after SSCA approval,
the data is used to replace DFDR downloads for incidents then a similar standard is
required. However, in the event of a QAR being unserviceable then the DFDR would of
course be available provided a timely download is made. The confirmation of acceptable
data on the QAR must always take place within the DFDR overwriting time-scale.
The following are core events being observed and evaluated through the FDM program
that cover the Company’s main areas of interest:
OPS APPROACH:
• GO AROUND - go-around
• AP DISC BLW 100 FT - AP disconnect below 100 ft
• THR RED LDG LATE - late thrust reduction at landing
• THR PUMP IN APP - throttles pumping during final approach
• UNSTAB APP - unstabilized approach below 1000 ft
• LDG GR LATE EXT - late landing gear extension
• LDG GR EXT SEQNCE – landing gear out of sequence
• SPD BRK DIS BLW 1000 FT - speedbrakes not armed below 1000 ft
• SPD BRK IN APP - use of speedbrakes during final approach
• SPD BRK CONF 3/FULL - use of speedbrakes with config > 2
• LATE FLP LDG CONF - late flap setting for landing
• LOC DEV BLW 1000 FT - localizer deviation below 1000 ft
• GS DEV BLW 1000 FT - glideslope deviation below 1000 ft
• HDG DEV BLW 500 FT - heading deviation during final approach, below 500 ft
• HEIGHT LO 2 MIN LDG - height low during approach, 2 minutes before landing
• HEIGHT LO 1 MIN LDG - height low during approach, 1 minute before landing
• HEIGHT HI 2 MIN LDG - height high during approach, 2 minutes before landing
• HEIGHT HI 1 MIN LDG - height high during approach, 1 minute before landing
• PITCH CYCL FINAL APP - pitch cycling during final approach
• DESC HI (500 - 35 FT) - high rate of descent during approach (500 - 35 ft)
OPS TAKE-OFF
• REJECTED TAKEOFF - rejected take-off
• LDG GR LATE RET - late landing gear retraction
• CONF CHG INIT CLB - early configuration change during initial climb
CHAPTER 3 P: 3-32
• HDG DEV ABV 100 KT - heading deviation during take-off roll, above 100 kt
• EARLY TURN TO - early turn –take-off
• HEIGHT LOSS INT CLB - height loss during initial climb
• HDG DEV BLW 500 FT - heading deviation below 500 ft
• PITCH RATE LOW < 50 FT - pitch rate high during take-off (below 50 ft)
• PITCH RATE HI < 50 FT - pitch rate high during take-off (below 50 ft)
• PITCH LO INIT CLB - low pitch between 35 and 400 ft
• PITCH HI LIFT OFF - high pitch at lift-off
• PITCH HI INIT CLB - high pitch between 35 and 1500 ft
• ACCL VRT HI TKOFF - high positive vertical acceleration during take-off
• SPD LO INIT CLB - low speed during initial climb
• SPD LO LIFT OFF - low speed at lift-off
OPS DESCENT
• DESCENT LO SLOPE - low descent slope over 10.000 ft
OPS FLIGHT
• TCAS - TCAS warning
• GPWS WDSHR BLW 1500 - windshear warning below 1500 ft
• GPWS WARNING - GPWS warning
• ROLL HI ABV 400 FT - roll exceedance above 400 ft
• ROLL HI BLW 1500 FT - roll exceedance below 1500 ft
• HEAD DEV BLW 300 FT - heading deviation below 300 ft
• TURB - turbulences
• ACCL VRT NEG HI - high negative vertical acceleration in flight
• ACCL VERT POS HI - high positive vertical acceleration in flight
OPS LANDING
• LOW FLAPS LDG - incorrect flap setting at landing
• LDG HDG DEV > 50 KT - heading deviation during landing, above 50 kt
• PITCH LO ON LDG - low pitch at touchdown
• PITCH HI ON LDG - high pitch at touchdown
• PITCH HI BLW 50 FT - high pitch during landing flare
• ACCEL_LONG LDG - high braking on landing
• HARD LDG - hard landing

CHAPTER 3 P: 3-33
AFM WEIGHT
• OVR WGHT LDG - overweight landing
AFM ALTITUDE
• ALT OVER MAX AFM - maximum altitude exceedance
AIR REGULATIONS SPEED

• SPD HI BLW 5000 - high speed below 5000 ft
AFM SPEED
• SPD OVER MMO - exceedance over MMO
• SPD OVER VMO - exceedance over VMO
• SPD HI TIRES LDG - high speed over tire speed limit
• SPD HI LDG GR DN - high speed with landing gear extended
• SPI HI LDG GR RET - high speed at landing gear retraction
• SPD HI LDG GR EXT - high speed at landing gear extension
• SPD HI CONF FULL - high speed in configuration Full
• SPD HI CONF 3 - high speed in configuration 3
• SPD HI CONF 1+F - high speed in configuration 1+F
OPS APPROACH SPEED

• SPD>VAPP BLW 500 FT - speed over VAPP below 500 ft
OPS TAXI
• SPD HI TAXI - high speed during taxi
AGS analyses flight data continuously and automatically detects and classify events. The
detection of events is based on three levels of increasing severity. Class 1 events have
low possible impact on safety, class 2 events have moderate possible impact on safety,
while class 3 events have possible safety impact. All the events must be validated before
considering them as usable. Events of severity class 1 and 2 will normally only be subject
to statistical monitoring, except if a trend is identified that may cause problems and that
needs to be furthered investigated. Operational parameters that trigger class 3 events are
considered to directly endanger the flight safety. Class 3 events, when severity is
confirmed (validated), will normally be investigated, in order to analyse them, find out the
root cause and understand all the contributing factors that led to the event. Analysis results
shall be used for giving preventive measures only and not to be used for blaming any
individual.

CHAPTER 3 P: 3-34
Under FDM program, the information about observed adverse trends need to be regularly
distributed/shared to all appropriate Company department by the Safety Manager.
3.2.7.3 Organisation and Control of FDM Information
FDM data are compiled on a monthly basis. The data are then reviewed by a working
group to identify specific exceedances and emerging undesirable trends and to
disseminate the information to flight crews. FDM working group should meet once monthly.
It consists of the following members:
• Safety Manager - chairman;
• Flight Safety Officer;
• Maintenance & Engineering Department Representative:
• Flight Operations Department Representative;
• Pilots Representative.
Flight Safety Officer is responsible for monitoring and evaluating data obtained from FDM
programme, and compiling FDM reports. He should have good analytical, presentation and
management skills. He should continuously review detection limits to ensure that
Company’s current operating procedures are properly reflected.
Flight Operations Department Representative should be a practising or very recent pilot,

possibly a captain or instructor, who knows the Company’s route network and aircraft. His
in-depth knowledge of SOPs, aircraft handling characteristics, airports and routes will be
used to place the FDM data in context.
Maintenance & Engineering Department Representative will interpret FDM data on

technical aspects of the aircraft operation. He should be familiar with the power plant,
structures and systems department’s requirements for information and also any existing
monitoring techniques employed by the Company.
The Pilots Representative will be the link between the Flight Operations and Training
Managers and flight crew involved in circumstances highlighted by the FDM. This role may
be carried out by the Flight Safety Officer or another trusted individual. The Pilots
Representative position demands someone with good people skills and a positive attitude
towards safety education. It is essential he has the trust of both flight crew and managers
for their integrity and good judgement.
Safety Manager is accountable and holds overall responsibility for Flight Data Monitoring
Programme and its application.
FDM working group shall, in the following order:

• Analyse the event(s) using all available information;

CHAPTER 3 P: 3-35
• Prepare recommendations to Flight Operations Manager (or other Company’s

postholder, as applicable) for corrective and preventive measures;
• Decide by voting whether or not to identify the flight crew, as applicable.
Once a basic assessment has been carried out and has revealed a significant risk, or
aspect requiring further investigation or remedial action, then one particular person or
department should be allocated follow-up responsibility. FDM working group will review
analysis and identify hazards. The implementation of corrective actions, fully or partially, is
the responsibility of the Company’s postholders who shall be fully empowered. In case the
corrective (remedial) action to reduce the level of risk to acceptable level is required, it
should be assessed for any wider possible effects of any proposed changes. This should
be carried out to ensure the risk or problem is not moved elsewhere. On occasions there
may be a need to involve several departments or even organisations and in this case a
coordinator should be designated who will act as a focal point for the investigation and
corrective actions.
The main purpose of corrective action is re-establishment of compliance with the

applicable regulation or standard. Responsible person bears full responsibility and
accountability for corrective action implementation in timely manner. Reasonable period of
time should be allocated for corrective actions to be undertaken reflecting the severity of
the issue.
FDM working group will close the loop by tracking the effectiveness of the corrective
actions.
Corrective action should be considered successfully accomplished when it:

• Is effective in restoring the compliance with the applicable regulation or standard;
and
• Provides acceptable assurance that same or similar parameter exceedance (event)
will not re-occur.
Once any corrective action is take, then an active monitor should be placed on the original
problem and a careful assessment made of other hazards in the area of change. Part of
the assessment of the fuller effects of changes should be an attempt to identify unintended
consequences or the potential relocation of risks.
If FDM working group realizes the parameters that trigger events are not realistic or
accurate, they will request Flight Safety Officer to inform company Sagem to adjust set
parameters in order to comply with actual operations conditions.
All the members of FDM working group shall sign the confidentiality contract.

CHAPTER 3 P: 3-36
Specimen of Confidentiality Contract:
Confidentiality Contract
I understand that, in connection with my responsibilities as ____________________

(function), all the information I receive when performing my duties will be considered highly
confidential and sensitive.
I will not disclose my privilege access security to the FDM system to anyone nor grant access.
I will not try to identify date, flight number and/or crew by any means of any flight being
analysed unless identification is permitted as defined in the applicable FDM section of JC
Airlines Safety Management System Manual.
Except as required by law, or upon request of a court of law, I will not disclose, reproduce,
copy or otherwise make available to any third party in any way said confidential information.
I agree the non-disclosure undertaking made in this document will survive the termination of
my current employment.
I understand that any violation of this agreement may result in:
- Termination of my appointment as _____________ (function);

- Disciplinary sanctions as per individual contract, including dismissal;
- Prosecution to the full extent of the law.
The terms of this agreement will continue to be effective whether employed with JC Airlines or
not.
Signed on behalf of JC Cambodia International Airlines:
Name: ___________________________
Date: ____________________________
Signed:
Name: ___________________________
Date: ____________________________
If deficiencies in pilot handling technique are evident, the information is de-identified in

order to protect the identity of the flight crew. The information on specific exceedances
may be passed to the pilot concerned for confidential discussion, in order to clarify the
circumstances, obtain feedback, and give advice and recommendations for appropriate
action, such as re-training for the pilot (carried out in a positive and non-punitive way),
revisions to operating and flight manuals, changes to operating procedures, etc.

CHAPTER 3 P: 3-37
As well as reviewing specific exceedances, all events are archived in a database. The
database is used to sort, validate and display the data in easy-to-understand management
reports. Over time, this archived data will provide a picture of emerging trends and hazards
which would otherwise go unnoticed. Where the development of an undesirable trend
becomes evident (within a fleet, or at a particular phase of flight, or airport location), the
Training Department and/or Flight Operations Department can implement measures to
reverse the trend through modification of training exercises and/or operating procedures.
Likewise with other areas of the operation requiring action, the data can then be used to
confirm the effectiveness of any action taken.
Lessons learned from the FDM may warrant inclusion in the Company’s safety promotion
programmes. Regular safety reports/information or appropriate training, as applicable,
should be used for safety education. This shall be prepared by Safety Manager and/or
Flight Safety Officer. Care is required, however, to ensure that any information acquired
through FDM is studiously de-identified before using it in any training or promotional
initiative.
Once it has been ascertained that there is significant actual or potential risk associated
with an issue raised by any safety analysis process then it is widely accepted that there is
an obligation to:
• Act upon it to prevent a repetition;
• Spread the safety message both within the Company and to industry to prevent
someone else’s accident.
After recording and acting upon such information as an Air Safety Report (ASR) within the
company then the principal medium for informing is the Mandatory Occurrence Reporting
scheme. It is logical to feed the lessons obtained from FDM into this existing system.
While the reports generated automatically from FDM programmes should be treated
confidentially, the greatest benefit will be gained by correlating this information with other
relevant safety and technical reports especially in the case of the most hazardous or
significant events. Where an air safety report has already been submitted then (only)
relevant FDM events can be used to add to the understanding of the circumstances of the
incident. It is important to emphasise that it is not the purpose of the process to check out
the reporter’s recollection and accuracy.
Significant risk bearing incidents detected by FDM will normally be the subject of
mandatory occurrence report by the crew. If this is not the case then they should submit a
retrospective report that will be included under the normal accident prevention and flight
safety process without prejudice. Safety Department will check and confirm if a FDM
exceedance has been the subject of a crew safety report.
The FDM database should be linked to other safety databases. These might include
technical fault reporting systems and incident reporting systems. A more complete
understanding of events becomes possible by cross-referencing the various sources of
CHAPTER 3 P: 3-38
information. The confidentiality of the FDR data must be assured when databases are
shared in this way.
The data retention strategy enables the extraction of the greatest safety benefits
practicable from the available data. After a period, sufficient to complete the action and
review process, during which full data are retained, a reduced data set relating to closed
issues are maintained for longer term trend analysis. Identification data is to be erased
after 60 days, unless otherwise required by the investigation. De-identified data is to be
saved for 6 months and then destroyed. Safety trends and analysis are to be kept for at
least 2 years.
Additionally a representative sample of full flight data may be retained for detailed
retrospective analysis and comparison. JC Airlines shall preserve a record of one
representative flight made within the last 12 months. The purpose of this is to ensure that,
in the event of an accident/incident, air accident investigators have access to readout from
the flight data recording system that is representative of the actual aircraft condition prior
to the accident/incident. It follows that the data originating from the selected representative
flight will need to be evaluated to determine that it comprises a valid record.
JC Airlines will pass on the safety discoveries and lessons learnt from FDM to all relevant
personnel and, where appropriate, to outside aviation stakeholders, utilising similar media
to current air safety systems. These may include:
• Newsletters;
• Flight safety magazines;
• Highlighting examples in training and simulator exercises;
• Periodic reports to industry and the regulatory authority.
FDM data in any form are to be treated with the highest level of confidentiality. FDM is
based on the non-punitive approach and on the anonymity principle which must be
protected by all means. Any misuse of FDM data (e.g. unauthorised public disclosure) may
adversely affect Company’s interests and indirectly reduce the level of flight safety.
Employees not complying with the rules of confidentiality will be subject to serious
disciplinary and/or legal actions.
Anonymity and/or immunity to flight crew members involved in operational event should be
assured if:
• ASR is filed by applicable flight crew not later than five days after the event; and
• Event is classified by AGS as maximum class 2 event.
On behalf of the Company it is prohibited to use FDM data for the purpose of the selection
of the employees. Punishment or prosecution of the employees, based on FDM data, is
not allowed, except in cases where official Authority investigation is underway.

CHAPTER 3 P: 3-39
FDM data shall only be provided to the Authority consequently to the official investigation
order. Provided FDM data amount shall strictly be limited to the specific flight under
investigation.
Any JC Airlines’ employee or contracted third party personnel, who has contact with any
identified data used in FDM program shall be prohibited from revealing any identifying data
to any individual other than the FDM team members.
FDM data shall be protected including:

• Not to be used for disciplinary purposes;
• Not to be used for enforcement actions against individuals or against the Company,
except in cases of criminal intent or intentional disregard of safety;
• Not to be disclosed to the media and the general public under the provisions of
State laws for access to information;
• Not to be disclosed during civil litigation.
An operator shall ensure, to the extent possible, in the event the aeroplane becomes
involved in an accident or incident, the preservation of all related flight recorder records
and, if necessary, the associated flight recorders, and their retention in safe custody
pending their disposition. After an incident or accident, a quick judgement has to be made
as to whether FDR data is likely to be useful in an investigation, hence the associated
flight recorder data have to be retained and protected. The short recycling/overwriting time
of most DFDRs makes it critical that a decision to quarantine the data is taken very rapidly.
Those incident and accident data requirements as specified in ICAO Annex 6 Part 1 (11.6)
and Annex 13 take precedence to the requirements of a FDM system. In these cases the
FDR data should be retained as part of the investigation data and may fall outside the de-
identification agreements. The responsibility for data collection, protection and evaluation
applies as defined in paragraph 3.2.7.2.
JC Airlines data recovery strategy should ensure a sufficiently representative capture of

flight information to maintain an overview of operations. Data collection should reach a
minimum of 50% of all relevant flights conducted by JC Airlines. Data analysis are
performed in a manner to ensure timely knowledge of immediate safety issues, the
identification of operational issues and to facilitate any necessary operational investigation
before crew memories of the event can fade.
JC Airlines data access and security policy restrict information access to authorised
persons.
Any flight crew member may request data about his own flight. Both pilots of the flight, for
which the data is requested, should agree in writing and the Commander will make a
request to the Safety Manager or Flight Safety Officer. Commander will specify the flight
information (flight number, data, time and aircraft registration) and the reason for the
request. Safety Manager will then decide whether the reasons for the acquisition of data

CHAPTER 3 P: 3-40
have valid grounds. Safety Manager or Flight Safety Officer will reveal the information to
both flight crew members in a confidential way.
In order to check the FDM for quality of event detection and analyses, irregular checks
may be carried out by intentionally exceeding some operational parameters (FDM check
flight). Operational parameter exceedance during FDM check flights has to be carried in a
safe and controlled environment by the authorised Commander according to an agreed
plan (no passengers on board, etc.). FDM check flight has to be approved by Chief Pilot
and pre-agreed by the Flight Safety Officer. Flight Safety Officer has to carry out the
investigation, find the problem and prescribe corrective actions if the check flight event is
not discovered and correctly analysed by the FDM.
The aircraft operator shall maintain the serviceability of the flight recorders through
operational checks. An annual inspection of the FDR recordings should be made, however
in the case where the aircraft is subject to an FDM programme this could be relaxed. For
this alleviation to be acceptable, the data source of FDR mandatory flight parameters and
of FDM data should be the same, the FDR should be fitted with reliable built-in-test
equipment (most solid-state FDRs are, but magnetic tape FDRs are not) and the integrity
of the FDR mandatory flight parameters should be monitored by the FDM programme.
Hence, under certain conditions, an FDM programme can be an acceptable substitute for
the annual inspection of the FDR recording.
3.2.7.4 FDM Reports
Safety Manager, together with Flight Safety Officer, shall produce FDM reports to
postholders at required time intervals as defined in the table below:
Report Maximum
Event Data
Recipient Time Interval
Report shall contain (de-identified, statistically analysed)
operational and maintenance events data with
emphasis on the following:
• List of all events since last report;
• Events classification;
• Events grouping with respect to aeroplane type, if
Accountable
12 months applicable;
Manager
• Events grouping with respect to flight operational
• activities;
• Events grouping with respect to maintenance
activities;
• Appropriate description of most serious events with
trend analyses since last report.
Report shall contain complete data (de-identified,
Safety 6 months or on statistically analysed) on all recorded operational and
Manager specific request maintenance events with trend analyses since last
report.
CHAPTER 3 P: 3-41
Report shall contain complete data (de-identified) on all

12 months or
Chief recorded operational and maintenance events on
on specific
Pilot applicable aeroplane type with trend analyses since last
request
report.
operational events data with emphasis on the following:
• List of all operational events since last report;
• Events classification;
Training • Events grouping with respect to aeroplane type, if
12 months
Manager applicable;
• Events grouping with respect to flight phase;
• Detailed description (with stated flight parameters)
of most serious events with trend analyses since
last report.
maintenance events data with emphasis on the
following:
• List of all maintenance events since last report;
Engineering/ 12 months or • Events classification;
Maintenance on specific • Events grouping with respect to aeroplane type, if
Manager request applicable;
• Events grouping with respect to ATA chapter;
• Detailed description (with stated technical
parameters) of most serious events with trend
analyses since last report.
Flight Report shall contain (de-identified, statistically analysed)
Operations 12 months operational events data with trend analyses since last
Manager report.
On specific Report shall contain all requested data on specific flight
Authority which is under official investigation with trend analyses
request
since last report.
FDM Reports should be established at least in the following forms:

a) Bi-annually/annually FDM reports;
b) Specific reports for de-briefing;
c) Reports for mandatory investigation of accident/incident;
d) Reports on analysis of flight operations safety trend;
e) Reports on safety risks assessment;
f) Other reports for flight data monitoring functions.
3.2.7.5 FDM Confidentiality Agreement
All data gathered under FDM programme are de-identified as to the flight number, day and
time of the flight. The identifying information will be removed during the analysis process
and crew identity will not be revealed at any stage. The focus of effective FDM programme

CHAPTER 3 P: 3-42
is on identifying system deficiencies, both internal and external, that may affect flight
safety.
Before Flight Data Monitoring begins, an agreement between the Company and its pilots,
outlining the protection of the identity of the individual in the FDM Programme should be
clearly written and signed.
Specimen of such agreement:
FDM Procedural and Confidentiality Agreement between

JC CAMBODIA INTERNATIONAL AIRLINES and its PILOTS
1 Introduction
1.1 The Flight Data Monitoring (FDM) Programme, known also as Flight Data Analysis
(FDA) Programme, forms part of JC Cambodia International Airlines’ (JC Airlines’) Safety
Management System. Recorded flight data can contain information that has the potential to
improve flight safety, but also has the potential, if used inappropriately, to be detrimental to
individual crew members or to the airline as a whole.
This document describes protocols that will enable the greatest safety benefit to be obtained
from the data whilst satisfying the Company’s need to be seen to be managing safety, and
simultaneously ensuring fair treatment of employees.
1.2 The FDM Programme conforms to the intent of JC Airlines that “The purpose of an
investigation of any accident or incident is to establish the facts and cause, and therefore
prevent further occurrence. The purpose is not to apportion blame or liability.”
1.3 It also conforms to the intent of ICAO Annex 6 (Part 1, Chapter 3) “A flight data
monitoring/analysis programme shall be non-punitive and contain safeguards to protect the
source(s) of the data”.
1.4 It has been accepted by both JC Airlines and its pilots that the greatest benefit will be
derived from the FDM Programme by working in a spirit of mutual cooperation towards
improving flight safety. A rigid set of rules can, on occasions, be obstructive, limiting or
counter-productive, and it is preferred that those involved in the FDM Programme should be
free to explore new avenues by mutual consent, always bearing in mind that the FDM
Programme is a safety programme, not a disciplinary one. The absence of rigid rules means
that the continued success of the FDM Programme depends on mutual trust - indeed this has
always been a key feature of the programme.
2 Statement of Purpose
2.1 The primary purpose of monitoring operational flight data by the FDM programme is to
enhance flight safety. The actions to be taken to reverse an adverse trend, or to prevent the
repetition of an event, may include raising pilot awareness, changing procedures and/or
manuals and seeking to change pilot behaviour (individually or collectively), amongst others.

CHAPTER 3 P: 3-43
2.2 Interested third parties (Manufacturer, Regulator or Research body) may seek access
to FDM data for safety purposes.
2.3 If the request is for de-identified data (i.e. the data does not contain any information that
would enable the data to be identified as originating from a particular flight), then JC Airlines
may supply this information and will notify the Pilots Representative on each occasion.
2.4 If, on the other hand, the requested data only has value when it can be linked to
specific flights, then JC Airlines will agree with the Pilots Representative the terms under which
the data can be provided.
2.5 Where FDM data is to be used for continued airworthiness or other engineering
purposes within the Company, then secure procedures must be in place to control access to
the data. Identification of and contact with crews will not be permitted through this path.
2.6 A general intention is that concerns raised by the FDM Programme should, where
possible, be resolved without identifying the crew concerned. However there may be
occasions when anonymity is not appropriate, and this document gives protocols to be
followed on such occasions in order to be in accordance with JC Airlines’ Safety Management
System procedures.
3 Constitution
3.1 The constitution and responsibilities of the FDM working group are defined in JC
Airlines’ SMS. The Group meets once a month. Membership consists of:
- Safety Manager (meeting chairman);

- Flight Safety Officer;
- Maintenance & Engineering Department Representative:
- Flight Operations Department Representative;
- Pilots Representative.
4 Confidentiality
4.1 This section applies to “events” discovered by the routine running of the FDM
Programme. JC Airlines will not identify flight crew involved in FDM events, except as in 4.1.1,
4.1.2 and 4.1.3 below.
4.1.1 If a pilot files an Air Safety Report (ASR) or reports an event, then the responsibility for
investigation lies with the affected department, although the FDM Programme may provide
assistance. In this case the pilot is, of course, identified.
4.1.2 In the case of repeated events by the same pilot in which the FDM working group
members feel extra training would be appropriate. A pilot may be required to undertake such
extra training as may be deemed necessary after consultation between the Pilots
Representative and representatives of Flight Operations Department, Training Department
and Safety Department. JC Airlines will arrange the training, and the Pilot Representative will
liaise with the pilot.

CHAPTER 3 P: 3-44
4.1.3 In other cases of repeated events by the same pilot; 'or a single pilot-induced event of
such severity that the aircraft was seriously hazarded, or another flight would be if the pilot
repeated the event. The pilots recognise that in the interests of flight safety, they cannot
condone unreasonable, negligent or dangerous pilot behaviour and, at JC Airlines request, will
normally consider withdrawing the protection of anonymity. This consideration by the pilots will
be undertaken by the Pilots Representative and previously agreed additional pilot members.
The pilot will be notified by the Pilots Representative that anonymity is being withdrawn, and
advised that he or she may be accompanied at any subsequent interview by the Pilots
Representative. If agreement cannot be reached between JC Airlines Flight Operations
Department and the pilots as to whether an event is sufficiently serious to warrant withdrawal
of anonymity, then a final decision will be taken by a nominated person. This person will be
either JC Airlines Safety Manager or another nominated senior JC Airlines Manager, and
he/she will be confirmed in this role by the pilots (through their representative), who will
reaffirm this acceptability each year.
5 Contact with Pilots
5.1 It is accepted that an FDR trace may give an incomplete picture of what happened, and
that it may not be able to explain "why” it happened. The Pilots Representative may be asked
to contact the pilot(s) involved to elicit further information as to "how" and "why" an event
occurred, The Pilot Representative may also be asked to contact a pilot to issue a reminder of
Company policy and/or procedures. In this case the Pilots Representative will identify and
contact the staff concerned.
5.2 Wilful disregard of SOPs. If a pilot is discovered, through the FDM Programme only, to
have wilfully disregarded JC Airlines SOPs, then he will be treated as follows:
If the breach of SOP did not endanger the aircraft or its occupants, then debriefing may be
carried out by the Pilot s Representative, thus preserving anonymity; but the pilot will be sent a
letter containing a clear warning that a second offence will result in withdrawal of anonymity.
The same applies in the case of a single event, or series of events, that is judged sufficiently
serious to warrant more than a telephone call, but not sufficiently serious to make an
immediate application for the withdrawal of anonymity under paragraph 4.1.3
If the breach of SOP did endanger the aircraft or its occupants, then JC Airlines will request
withdrawal of anonymity as in paragraph 4.3 above.
5.3 Contact will initially be with the Captain of the flight, but where human factors are
thought to be involved it may also be necessary to contact the First Officer or other flight crew
members.
5.4 It is recognised that the value of the Pilots Representative calls to the pilots could be
demeaned by over-use. Therefore the number of calls, and the value of each, will be
monitored by the FDM working group.
5.5 If a pilot fails to co-operate with the Pilots Representative with regard to the provisions
of this agreement, then JC Airlines will receive the Pilots Representative's approval to assume
responsibility for contact with that pilot, and any subsequent action,

CHAPTER 3 P: 3-45
6 The Pilots Representatives’ Access to Confidential Information
6.1 In order to fulfil his FDM Programme obligations, the Pilots Representative will need
access to information which is confidential to JC Airlines, and may be subject to the data
protection regulations. Upon appointment, a representative will be required to sign a
confidentiality agreement which specifies the terms under which information obtained from JC
Airlines may be used. Breach of this agreement may be the subject of JC Airlines’ disciplinary
procedures.
6.2 In order to contact the crew involved in a FDM Programme event (see section 5), the
Pilots Representative will need:
- The identity of the flight (date, registration and flight number);

- The ability to identify the crew of that flight, and how to contact them; and
- An electronic copy of the flight data and a means of viewing it.
Signed on behalf of JC Cambodia International Airlines:
Name: ___________________________
Date: ____________________________
Signed on behalf of JC Cambodia International Airlines’ pilots (Pilot Representative):
Name: ___________________________
Date: ____________________________
3.2.7.6 FDM and Mandatory Occurrence Reporting
Once it has been ascertained that there is significant actual or potential risk associated
with an issue raised by any safety monitoring process then it is widely accepted that there
is an obligation to:
• Act upon it to prevent a repetition;
• Spread the safety message both within the Company and to industry to prevent
someone else’s accident.
After recording and acting upon such information as an internal safety report within the
Company then the principal medium for broadcast to Cambodian authority (and flight
industry) is the Mandatory Occurrence Reporting (MOR) scheme. It is logical to feed the
lessons/data obtained from FDM into this existing system.
FDM system has proven to be very effective in reminding crews to submit reports during
the early stages of the programme and is then a useful audit tool, confirming reporting
standards in an established programme.

CHAPTER 3 P: 3-46
The following is the list of occurrences, for which a mandatory occurrence report shall be
filled:
• Hard landing;
• Tailstrike;
• Rejected take-off at high speed and go-arounds;
• Stall warning;
• Hard GPWS warning;
• High speed warning;
• Major system warning;
• Engine failure;
• Altitude deviation;
• Flight control difficulties indicated by excessive/untypical control deflections;
• Severe turbulence.
In case significant incidents and occurrences are found as a result of FDM analysis, the
crews will be encouraged to submit retrospective reports – without prejudice or penalty to
the crew concerned, if they have not already done so.
In cases of general underlying trends and wider issues, then FDM data alone may be used
to raise internal safety reports or MORs. In such cases it is expected that the reporter will
submit a single occurrence report together with the supporting evidence of high frequency
and/or rate when it is considered that such a situation has been reached.
Multiple FDM events may come together to indicate a potential issue for wider
consideration or action. Type of issues that are appropriate for such submission include:
• Unacceptable number of unstabilized approaches at a particular aerodrome;
• False/nuisance GPWS warnings at a particular location or with certain equipment;
• Repeated near tailstrikes due to pilot rotation technique indicating revised guidance
required;
• Reduced fuel reserves on certain sectors.
An exception to the de-identification of FDM data should be made when there is an

incident that is subject to a Mandatory Occurrence Report. In this case the identified data
must be retained for any subsequent safety investigation.
3.2.8 Line Operations Safety Audits
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.
CHAPTER 3 P: 3-47
Similar to Flight Data Monitoring (FDM) programmes, LOSA facilitates hazard identification
through the analysis of actual in-flight performances. Whereas FDM provides accurate
data on exceedances from expected aircraft performance, LOSA provides information on
joint system and human performance. It facilitates understanding the context for the
performance that may have precipitated the exceedance.
LOSA is a tool for the understanding of human errors in flight operations. It is used to
identify the threats to aviation safety that lead to human errors, to minimize the risks that
such threats may generate and to implement measures to manage these errors within the
operational context. LOSA enables operators to assess their resistance to operational
risks and errors by front-line personnel. Using a data-driven approach, they can prioritise
these risks and identify actions to reduce the risk of accidents.
By observing normal day-to-day flight operations, data about flight crew performance and
situational factors are collected. Thus, LOSA facilitates understanding of both successful
performance and failures. Hazards deriving from operational errors can be identified and
effective countermeasures developed.
LOSA uses experienced and specially trained observers to collect data about flight crew
performance and situational factors on “normal” flights. During observed flights, observers
record error-inducing circumstances and the crew’s responses to them, whether correct or
incorrect. The observations are conducted under strict non-punitive conditions, without fear
of disciplinary action for detected errors. Flight crews are not required to justify their
actions.
Data from LOSA also provide a picture of system operations that can guide strategies in
regard to safety management, training and operations. Like FDM programmes, data
collected through LOSA can provide a rich source of information for the proactive
identification of systemic safety hazards. A particular strength of LOSA is that it identifies
examples of superior performance that can be reinforced and used as models for training.
With LOSA, training interventions can be based on the most successful operational
performance. For example, based on LOSA data, CRM training can be modified to reflect
best practices for coping with particular types of unsafe conditions and for managing
typical errors related to these conditions.
During normal flights, crews routinely face situations created outside the cockpit that they
must manage. Such situations increase the operational complexity of their task and pose
some level of safety risk. These threats may be relatively minor (such as frequency
congestion), through to major (such as an engine fire warning).
Some threats can be anticipated (such as a high workload situation during approach) and
the crew may brief in advance, for example, “In the event of a go-around ...”. Other threats
may be unexpected. Since they occur without warning, no advanced briefing is feasible
(for example, a TCAS advisory).

CHAPTER 3 P: 3-48
Errors are a normal part of all human behaviour. Flight crew errors tend to reduce the
margin of safety and increase the probability of accidents. Fortunately, humans are
generally quite effective in balancing the conflicting demands between “getting the job
done” and “getting the job done safely”. Any action or inaction by the flight crew that leads
to deviations from expected behaviour is considered an error. Examples of crew errors
might include non-compliance with regulations and SOPs, or unexpected deviation from
company or ATC expectations. Errors may be minor (setting the wrong altitude, but
correcting it quickly) or major (not completing an essential checklist item).
LOSA employs five categories of crew errors. These include:

a) Communication error: Miscommunication, misinterpretation, or failure to
communicate pertinent information among the flight crew or between flight crew and
an external agent (for example, ATC or ground operations personnel);
b) Proficiency error: Lack of knowledge or psychomotor (“stick and rudder”) skills;
c) Operational decision error: Decision-making error that is not standardized by
regulation or Company procedures and that unnecessarily compromises safety (for
example, a crew decision to fly through a known wind shear on approach instead of
going around);
d) Procedural error: Deviation in execution of regulatory and/or Company procedures.
The intention is correct but the execution is flawed. This category also includes
errors where a crew forgot to do something;
e) Intentional non-compliance error: Wilful deviation from regulations and/or Company
procedures (i.e. violations).
Since threats and errors are an integral part of daily flight operations, systematic
understanding of them is required for safely dealing with them. Accepting that error is
inevitable, the most effective countermeasures go beyond trying to simply prevent errors.
They need to highlight unsafe conditions early enough to permit flight crews to take
corrective action before adverse consequences result from the error. In other words, they
“trap” the error.
The most effective countermeasures seek to improve the everyday work situation in which
flight crews face the inevitable threats to safe performance, measures which give crews a
“second chance” to recover from their errors. Such systemic countermeasures include
changes in aircraft design, crew training, company operating procedures, management
decisions, etc.

CHAPTER 3 P: 3-49
The key steps to LOSA

CHAPTER 3 P: 3-50
The following characteristics of LOSA ensure the integrity of the methodology and its data:
a) Jump seat observations during normal flight operations: LOSA observations are
limited to routine flights (as opposed to line checks, or other training flights). Check
pilots add to an already high stress level, thus providing an unrealistic picture of
performance. The best observers learn to be unobtrusive and non-threatening,
recording minimum detail in the cockpit;
b) Joint management/pilot sponsorship: In order for LOSA to succeed as a viable
safety programme, both management and pilots support the project;
c) Voluntary crew participation: Maintaining the integrity of LOSA within the airline is
extremely important for long-term success. One way to accomplish this goal is to
collect all observations with voluntary crew participation. Before conducting LOSA
observations, an observer obtains the flight crew’s permission. If an airline
conducting LOSA has an unreasonably high number of refusals by pilots to be
observed, this may indicate that there are critical “trust” issues to be dealt with first;
d) Collection of only de-identified, confidential safety data: LOSA observers do not
record names, flight numbers, dates or any other data that can identify a crew. This
allows for a high level of protection against disciplinary action. LOSA must not only
be seen to be non-punitive, it must be non-punitive;
e) Targeted observations: All data are collected on a specifically designed LOSA
Observation Form. Typically, the following types of information are collected by the
LOSA observer:
• Flight and crew demographics such as city pairs, aircraft type, flight time,
years of experience in that position and with that airline, and crew familiarity;
• Written narratives describing what the crew did well and what they did poorly
and how they managed threats or errors for each phase of the flight;
• CRM performance ratings using validated behavioural markers;
• Technical worksheet for the descent/approach/landing phases that highlight
the type of approach flown, the landing runway and whether the crew met the
parameters of a stabilized approach;
• Threat management worksheet that details each threat and how it was
handled;
• Error management worksheet that lists each error observed, how each error
was handled and the final outcome;
• Crew interview conducted during low workload periods of the flight, such as
cruise, that asks pilots for their suggestions to improve safety, training, and
flight operations.
f) Trusted, trained and standardized observers: Observers are primarily pilots drawn
from the line, training department, safety department, management, etc. They may
also come from a non-affiliated airline. Regardless of the source, it is critical that the
observers are respected and trusted to ensure acceptance of LOSA by the line
pilots. The observers must be trained in concepts of threat and error management
and in the use of the LOSA rating forms. Standardized rating is vital to the validity of
the programme;
CHAPTER 3 P: 3-51
g) Trusted data collection site: In order to maintain confidentiality, JC Airlines has a

trusted data collection site. No observations shall be misplaced or improperly
disseminated within the airline, not to compromise LOSA integrity;
h) Data verification round-tables: Data-driven programmes like LOSA require data
quality management procedures and consistency checks. For LOSA, round table
discussions with representatives of management and the pilots scan raw data for
inconsistencies. The database must be validated for consistency and accuracy
before a statistical analysis can proceed;
i) Data-derived targets for enhancement: As the data are collected and analysed,
patterns emerge. Certain errors occur frequently, certain airports or activities are
problematic, certain SOPs are ignored or modified, and certain manoeuvres pose
particular difficulties. These patterns become targets for enhancement. The airline
then develops an action plan and implements appropriate change strategies based
on the input of expertise available to the airline. Through subsequent LOSA audits,
the effectiveness of the changes can be measured;
j) Feedback of results to the line pilots: After a LOSA is completed; the airline’s
management team has an obligation to communicate the findings to the line pilots.
Pilots are interested not only in the results but also management’s plan for
improvement.
3.2.9 Cabin Safety
Cabin operations play a critical role in the safety of air transport. Historically, the role of
cabin crew was seen as limited to evacuations in a post-accident scenario. Although this
remains an essential duty of cabin crew, today the role of cabin crew goes beyond
passenger evacuations. Cabin safety deals with all activities that cabin crew must
accomplish during the operation of an aircraft to maintain safety in the cabin. Cabin crew
contribute to safe, effective, and efficient operations in normal, abnormal and emergency
situations. As demonstrated in numerous events, cabin crew play an important role in
preventing accidents and serious incidents, including but not limited to events such as
such as an in-flight fire, unruly passenger or decompression.
The provision of cabin service may be viewed as a marketing or customer service function;
however, cabin safety is clearly an operational function. Corporate policy should reflect
this, and management needs to demonstrate its commitment to cabin safety with more
than words. Common indicators of management’s commitment to cabin safety include:
a) Allocation of sufficient resources (adequate staffing of cabin crew positions, initial
and recurrent training, training facilities, etc.);
b) Clearly defined responsibilities, including the setting, monitoring and enforcing of
practical SOPs for safety;
c) Fostering of a positive safety culture.

CHAPTER 3 P: 3-52
Cabin safety is a critical component of aviation safety as is an airline’s safety management

system which includes proactive data collection and the ensuing prevention activities
regarding:
• Equipment;
• Procedures;
• Cabin crew training;
• Human performance and crew resource management;
• Passenger management.
Creating a positive safety culture for cabin crew begins with departmental organization.
The cabin crew shall receive their principal direction from the Flight Operations
Department with the main focus on cabin safety. Other considerations for the promotion of
a positive safety culture include the relationship between flight crew and cabin crew, for
example:
a. Spirit of cooperation, marked by mutual respect and understanding;
• Effective communications between flight crew and cabin crew;
• Regular review of SOPs to ensure compatibility between flight deck and
cabin procedures;
• Joint pre-flight briefings for flight crew and cabin crew;
• Joint debriefings following safety-related occurrences, etc.;
b. Cabin crew participation in safety management:
• Involvement of the safety manager in cabin safety issues;
• Avenues for offering cabin safety expertise and advice (safety committee
meetings, etc.);
• Participation in developing policies, objectives and SOPs affecting cabin
safety;
• Participation in company’s incident reporting system, etc.
As in flight deck operations, cabin safety requires strict adherence to well-thought-out and
practical SOPs, including the use of checklists and briefings of cabin crew. Procedures
include, but are not limited to the following:
• Passenger boarding;
• Seat assignment;
• Stowage of carry-on baggage;
• Emergency exit accessibility and availability;
• Passenger safety briefing;
• Service equipment storage and use;
• Emergency medical equipment storage and use (oxygen, first aid kit, etc.);
• Handling of medical emergencies;

CHAPTER 3 P: 3-53
• Non-medical emergency equipment storage and use (fire extinguishers, protective

breathing equipment, etc.);
• In-flight emergency procedures (smoke, fire, etc.);
• Cabin crew announcements;
• Turbulence procedures (including securing the cabin);
• Handling unruly passengers;
• Emergency evacuations;
• Routine deplaning.
Cabin crew members shall report hazards, incidents and safety concerns as they become
aware of them without fear of embarrassment, incrimination or disciplinary action.
Cabin crew duties and responsibilities are safety-related, and cabin crew training should
clearly reflect this fact. While training can never duplicate all the types of situations that
may confront cabin crew, training can instil basic knowledge, skills, attitudes and
confidence that will allow cabin crew to handle emergency situations. In JC Airlines cabin
crew training therefore includes:
• Initial indoctrination covering basic theory of flight, meteorology, physiology of flight,
psychology of passenger behaviour, aviation terminology, etc.;
• Hands-on training (if practicable using cabin simulators for fire, smoke and
evacuation drills);
• In-flight supervision (on-job-training);
• Annual recurrent training and re-qualification;
• Knowledge and skills in CRM, including coordinating activities with the flight crew;
• Joint training exercises with flight crew to practice drills and procedures used in
flight and in emergency evacuations;
• Indoctrination in function and use of selected aspects of the company’s SMS (such
as hazard and incident reporting).
In an emergency, the expertise of the cabin crew will be required with little or no warning.
Thus, effective safety training for cabin crew requires practice to maintain the sharpness
necessary in an emergency.
Safety inspections, safety surveys and safety audits are tools that can be used to ensure
that requisite cabin safety standards are being maintained. Cabin safety standards will be
confirmed through an ongoing programme of:
• Aircraft inspections (e.g. emergency exits, emergency equipment, and galleys);
• Pre-flight (ramp) inspections;
• In-flight cabin inspections (e.g. passenger briefings and demonstrations, crew
briefings and use of checklists, crew communications, discipline, and situational
awareness);

CHAPTER 3 P: 3-54
• Training inspections (e.g. facilities, quality of instruction, and records); and

• Base inspections (e.g. crew scheduling, dispatch, safety incident reporting and
response, etc.).
A Company’s internal safety audit programme includes also the cabin crew department.
The audit process includes a review of all cabin operations, as well as an audit of cabin
safety procedures, training, the cabin crew’s operating manual, etc.
3.2.10 Occurrence Reporting

3.2.10.1 General
Occurrence reporting systems are one of the Company’s most effective tools for proactive
hazard identification, a key element of effective safety management.
In addition to Kingdom of Cambodia – state operated incident reporting system (both

mandatory and voluntary), JC Airlines has its own reporting system for the reporting of
safety hazards and incidents. As reporting is available to all personnel (not just the flight
crew), the Company’s reporting system is helping with promotion of a positive company-
wide safety culture.
ASR process flow:

CHAPTER 3 P: 3-55
Policies, procedures and practices developed within the Company may 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.
An accident or incident may not result from these hazards immediately because “front-line
personnel” (whether they be pilots, ATC or maintenance personnel) often develop ways of
coping with the hazard - sometimes described as “work arounds”. However, if the hazards
are not identified and addressed, sooner or later the coping mechanisms fail and an
accident or incident ensues.
A properly managed in-house reporting system helps the Company identify many of these
hazards. By collecting, aggregating and then analysing hazard and incident reports, Safety
Department can better understand problems encountered during operations. Armed with
this knowledge, they it can initiate systemic solutions, rather than short-term fixes that may
only hide the real problems.
• Safety management systems involve the reactive and proactive identification of

safety hazards. Accident investigations reveal a great deal about safety hazards;
but fortunately, aviation accidents are rare events. They are, however, generally
investigated more thoroughly than incidents. When safety initiatives rely exclusively
on accident data, the limitations of not having many case samples apply. As a
result, the wrong conclusions may be drawn or inappropriate corrective actions
taken.
• The number of incidents is significantly greater than the number of accidents for
comparable types of occurrences. The causal and contributory factors associated
with incidents may also culminate in accidents. Often, only good fortune prevents
an incident from becoming an accident. Unfortunately, these incidents are not
always known to those responsible for reducing or eliminating the associated risks.
This may be due to the unavailability of reporting systems, or people not being
sufficiently motivated to report incidents.
The principle objective of open reporting is not to apportion blame, but to identify causal
factors in order to prevent accidents and incidents. The purpose of the JC Airlines
reporting process is to enhance the Company’s knowledge of hazardous and potentially
hazardous situations.

CHAPTER 3 P: 3-56
Company and contracted personnel have a duty of care to report all safety issues. It is
recognized that human errors are inevitable and must be managed. Employees who report
unintentional errors will not suffer retribution.
JC Airlines employees are responsible for their actions. Deliberate violations of SOP or
reckless behaviours are not acceptable. Intentional noncompliance / violations or
deliberate failure to report safety occurrences will be managed in accordance with
Company disciplinary procedures.
For the purpose of the JC Airlines Safety Management System, a reportable occurrence
includes all of the following events:
• An event that degrades the safety of the operation, persons or property;
• An event that has the potential to degrade the safety of the operation, persons or
property;
• An event that reveals a quality deficiency.
In spite of Company’s firm determination regarding just culture concept there might be
situations where behaviour of the crew member cannot be tolerated.
Non-reprisal policy will be denied in cases:

• Where one commits safety threat deliberately; or
• Where one commits act based on negligence; and
• To persons that knowingly and willingly violate legal acts and/or Company
procedures and requirements.
In such cases crew member will not be protected against Company’s discipline actions
even if occurrence report has been filed by him.
3.2.10.2 Mandatory Occurrence Report
Mandatory Occurrence Report (MOR) is a report that must be submitted in accordance

with the provisions of State Secretariat of Civil Aviation of Kingdom of Cambodia.
In a mandatory system, people are required to report accidents and certain types of
incidents. This necessitates detailed regulations outlining who shall report and what shall
be reported. The number of variables in aviation operations is so great that it is difficult to
provide a comprehensive list of items or conditions which should be reported. A relatively
minor problem in one set of circumstances can in different circumstances result in
a hazardous situation. However, the rule should be: “If in doubt — report it.”
A reporte of a safety report should be informed about actions taken.

CHAPTER 3 P: 3-57
The following is a list of the types of occurrences or safety events to be reported under the
Company’s incident reporting system. The list is neither exhaustive nor in any order of
importance.
• Any system defect which adversely affects the handling or operation of the aircraft;
• Warning of smoke or fire, including the activation of toilet smoke detectors and
galley fires;
• An emergency is declared;
• The aircraft is evacuated by means of the emergency exits/slides;
• Safety equipment or procedures are defective, inadequate or used;
• Serious deficiencies in operational documentation;
• Incorrect loading of fuel, cargo or dangerous goods;
• Significant deviation from SOPs;
• A go-around is carried out from below 1.000 ft above ground level;
• An engine is shut down or fails at any stage of the flight;
• Ground damage occurs;
• A take-off is rejected after take-off power is established;
• The aircraft leaves the runway or taxiway;
• A navigation error involving a significant deviation from track;
• An altitude excursion of more than 500 ft occurs;
• Unstabilized approach under 500 ft;
• Exceeding the limiting parameters for the aircraft configuration;
• Communications fail or are impaired;
• A stall warning occurs;
• GPWS activation;
• A heavy landing check is required;
• Hazardous surface conditions, e.g. icy, slush and poor braking;
• Aircraft lands with reserve fuel or less remaining;
• A TCAS RA event;
• A serious ATC incident, e.g. near mid-air collision, runway incursion and incorrect
clearance;
• Significant wake turbulence, turbulence, wind shear or other severe weather;
• Crew or passengers become seriously ill, are injured, become incapacitated or
deceased;
• Violent, armed or intoxicated passengers, or when restraint is necessary;
• Security procedures are breached;
• Bird strike or Foreign Object Damage (FOD);
• Any other event considered likely to have an effect on safety or aircraft operations.
For detailed list of mandatory occurrence reports refer to OM Part A, Chapter 11.

CHAPTER 3 P: 3-58
The Company and its contracted third parties have an obligation under Cambodian Civil
Aviation Regulations (CCAR) to provide a copy of any Occurrence Report that is
considered to be a Mandatory Occurrence Report to the SSCA.
3.2.10.3 Voluntary/Confidential Occurrence Report
The Company’s Confidential Reporting Scheme follows the normal reporting procedure
except details to identify the reporter need not be provided (anonymously). This is open to
any JC Airlines employee to report any potentially unsafe act or procedure.
Reports may be submitted on the occurrence report form in a de-identified manner, and
put into Safety Confidential Information box. The report may also be submitted via e-mail
or any other communication medium.
Confidential reports will be accompanied by a non-punitive approach, except where

deliberate actions are proven.
All personnel should be cognisant that voluntary/confidential reports used for personal gain
could damage the company safety programme and are deemed unacceptable.
An occurrence report may be completed on a confidential basis by filing the Confidential

Occurrence Report form.
The following reports should not be submitted as confidential reports:

• Mandatory Occurrence Reports;
• Reports advising of emergency situations;
• Reports of violation of local regulations and/or procedures.
Confidential reports may be addressed and gathered by means of following:

• Personal delivery to Safety Department;
• Safety boxes (Flight Dispatch, Company main office, etc.);
• Scan and e-mail to safety@jcairlines.com.
JC Airlines’ voluntary/confidential reporting system defines:

• The objective of the reporting system;
• The scope of the aviation sectors/areas covered by the system;
• Who can make a voluntary report;
• When to make such a report;
• How the reports are processed;
• Contacting the Safety Manager.

CHAPTER 3 P: 3-59
The key objective of JC Airlines’ voluntary and confidential reporting system is to enhance
the safety of Company’s aviation activities through the collection of reports on actual or
potential safety deficiencies that would otherwise not be reported through other channels.
Such reports may involve occurrences, hazards or threats relevant to the safety of our
aviation activities. This system does not eliminate the need for formal reporting of
accidents and incidents according to our company SOPs, as well as the submission of
mandatory occurrence reports to the relevant regulatory authorities.
JC Airlines’ voluntary/confidential reporting system is a voluntary, non-punitive, confidential

occurrence and hazard reporting system administered by the Safety Department. It
provides a channel for the voluntary reporting of aviation occurrences or hazards relevant
to our organization’s aviation activities, while protecting the reporter’s identity.
Confidential reporting system aims to protect the identity of the reporter. This is one way of
ensuring that voluntary reporting system is non-punitive. Confidential incident reporting
system facilitates the disclosure of human errors, without fear of retribution or
embarrassment, and enable others to learn from previous mistakes.
JC Airlines’ voluntary/confidential reporting system covers the following areas:

• Flight operations;
• Ground operations;
• Engineering planning;
• Technical services and records;
• Line maintenance.
If you belong to any of these operational areas or departments, you can contribute to
aviation safety enhancement through the voluntary/confidential reporting system by
reporting on occurrences, hazards or threats relevant to our organization’s aviation
activities:
• Flight and cabin crew members;
• Air traffic controllers;
• Licensed aircraft engineers, technicians or mechanics;
• Airport ground handling operators;
• Company employees;
• Aerodrome employees.
You should make a report when:

• You wish for others to learn and benefit from the incident or hazard but are
concerned about protecting your identity;
• There is no other appropriate reporting procedure or channel;
• You have tried other reporting procedures or channels without the issue having
been addressed.
CHAPTER 3 P: 3-60
JC Airlines’ voluntary/confidential reporting system pays particular attention to the need to

protect the reporter’s identity when processing all reports. Every report will be read and
validated by the Safety Manager. The Safety Manager may contact the reporter to make
sure he understands the nature and circumstances of the occurrence/hazard reported
and/or to obtain the necessary additional information and clarification.
When the Safety Manager is satisfied that the information obtained is complete and
coherent, he will de-identify the information and enter the data into the safety system
database. Should there be a need to seek input from any third party, only the de-identified
data will be used.
The voluntary/confidential reporting form, with the date of return annotated, will eventually
be returned to the reporter. The Safety Manager will endeavour to complete the
processing within ten (10) working days if additional information is not needed. In cases
where the Safety Manager needs to discuss with the reporter or consult a third party, more
time may be needed.
If the Safety Manager is away from his office for a prolonged period, his deputy will
process the report. Reporters can rest assured that every voluntary/confidential report will
be read and followed through by either the Safety Manager or his deputy.
Relevant de-identified reports and extracts may be shared within the Company as well as
with external aviation stakeholders as deemed appropriate. This will enable all concerned
personnel and departments within the Company as well as appropriate external aviation
stakeholders to review their own operations and support the improvement of aviation
safety as a whole.
If the content of a voluntary/confidential report suggests a situation or condition that poses

an immediate or urgent threat to aviation safety, the report will be handled with priority and
referred, after de-identification, to the relevant organizations or authorities as soon as
possible to enable them to take the necessary safety actions.
JC Airlines’ personnel are welcomed to contact the Safety Manager to enquire about the
voluntary/confidential reporting system or to request a preliminary discussion with
the Safety Manager before making a report.
When the person making a safety report is known, he should be informed about actions
taken.

CHAPTER 3 P: 3-61
3.3 MANAGEMENT OF CHANGE
Unless properly managed, changes in organisational structure, personnel, documentation,

processes or procedures can result in the inadvertent introduction of hazards and
increased risk.
Therefore to minimize the potential of increasing risk the intended change has to be
thoroughly analysed in advance. Changes in operational procedures or processes, in
location, equipment or operating conditions shall be analysed to identify any required
changes in training, documentation, or equipment (e.g. safety risk assessment performed).
The systematic approach to managing and monitoring organizational change is part of the
risk management process. Safety issues associated with change are identified and
standards associated with change are maintained during the change process.
JC Airlines may experience constant changes due to possible:

• Expansion or contraction;
• Changes to existing systems, equipment, programmes, products and services;
• Introduction of new equipment or procedures.
Management of change includes the following procedures:

• Any new aviation safety related operations and processes should be reviewed for
hazards/risks before they are commissioned;
• Relevant existing aviation safety related facilities and equipment (including any
hazard identification and risk mitigation (HIRM) records) should be reviewed
whenever there are pertinent changes to those facilities or equipment;
• Relevant existing aviation safety related operations and processes (including any
HIRM records) should be reviewed whenever there are pertinent changes to those
operations or processes;
• Relevant existing facilities, equipment, operations or processes (including any
HIRM records) should be reviewed whenever there are pertinent changes external
to the Company such as regulatory/industry standards, best practices or
technology.
Hazards may inadvertently be introduced into an operation whenever change occurs.

Safety management practices require that hazards that are a by-product of change be
systematically and proactively identified and those strategies to manage the safety risks of
the consequences of hazards be developed, implemented and subsequently evaluated.
Safety reviews are a valuable source of information and decision making under
circumstances of change.
Change can introduce new hazards, impact the appropriateness of existing safety risk
mitigation strategies and/or impact the effectiveness of existing safety risk mitigation
strategies. Changes may be external to the organization, or internal. Examples of external
CHAPTER 3 P: 3-62
changes include changes in regulatory requirements, changes in security requirements,

etc. Examples of internal changes include management changes, new equipment and new
procedures.
In JC Airlines a formal process for the management of change takes into account the
following three considerations:
a) Criticality. Criticality assessments determine the systems, equipment or activities

that are essential to the safe operation of aircraft. While criticality is normally
assessed during the system design process, it is also relevant during a situation of
change. Systems, equipment and activities that have higher safety criticality should
be reviewed following change to make sure that corrective actions can be taken to
control potentially emerging safety risks.
b) Stability of systems and operational environments. Changes may be planned and

under the direct control of the organization. Such changes include organizational
growth or contraction, the expansion of products or services delivered, or the
introduction of new technologies. Unplanned changes may include those related to
economic cycles, labour unrest, as well as changes to the political, regulatory or
operating environments.
c) Past performance. Past performance of critical systems and trend analyses in the
safety assurance process should be employed to anticipate and monitor safety
performance under situations of change. The monitoring of past performance will
also assure the effectiveness of corrective actions taken to address safety
deficiencies identified as a result of audits, evaluations, investigations or reports.
A formal management of change process should then identify changes within the
organization which may affect established processes, procedures, products and services.
Prior to implementing changes, a formal management of change process should describe
the arrangements to ensure safety performance. The result of this process is the reduction
in the safety risks resulting from changes in the provision of services by the organization to
ALARP.
In order to promptly identify new hazards and new risks or increased risks, all managers
shall promptly notify the Safety Manager of any planned external or internal change with
impact on operational level. Received notification will be first assessed by the Safety
Manager, who will initiate the risk assessment process, if applicable.
Procedure for managing change includes the following steps:

• Safety risk assessment;
• Identification of the goals and objectives and nature of the proposed change;
• Operational procedures are identified;
• Changes in location, equipment or operating conditions are analysed;

CHAPTER 3 P: 3-63
• All personnel are made aware of and understand changes;

• Level of management with authority to approve changes is identified;
• The responsibility for reviewing, evaluating and recording the potential safety
hazards from the change or its implementation is assigned.
Complex intended changes shall be reviewed and analysed for any potential hazards/risks
by the applicable Safety Action Group (SAG) on base of the related task received from
Safety Review Committee (SRC) or from the Safety Manager, as applicable.
Based on the applicable Safety Action Group (SAG) report, final approval for change shall
be given by Safety Review Committee (SRC).

CHAPTER 3 P: 3-64
3.4 CONTINUOUS IMPROVEMENT OF THE SMS
Continuous improvement in safety is a core value. This is accomplished by measuring

safety performance and implementing necessary changes. In addition the Company will
ensure the following to continually improve its organisation:
• Adjust the Acceptable Level of Safety (ALoS) yearly to show improvements in
dealing with trends.
• Conduct risk management assessments on all identified hazards to minimize risks
associated with operations.
• Increase the submission of Hazard/Risk Identification Reports.
• Reduce the number of non-compliances with standard procedures.
• Increase compliance with the applicable regulation and best recognized industry
standards.
Objectives, Safety targets and Safety Performance Indicators (SPI) are discussed and
agreed during the Safety Review Committee (SRC) meetings.
Internal audits involve the systematic and scheduled examination of the Company’s
aviation activities, including those specific to implementation of the SMS. To be most
effective, internal audits are conducted by persons or departments that are independent of
the functions being evaluated. Such audits provide the Accountable Manager, as well as
senior management officials responsible for the SMS, the ability to track the
implementation and effectiveness of the SMS as well as its supporting systems.
External audits of the SMS may be conducted by relevant authorities responsible for
acceptance of the Company’s SMS. Additionally, audits may be conducted by industry
associations or other third parties selected by JC Airlines. These external audits enhance
the internal audit system as well as provide independent oversight.
In summary, the evaluation and audit processes contribute to the JC Airlines’ ability to
achieve continuous improvement in safety performance. Ongoing monitoring of the SMS,
its related safety controls and support systems assures that the safety management
process is achieving its objectives.
Purpose of continues improvement of safety system in JC Airlines is to:

• Determine the immediate causes of below standard performance and their
implication in the operation of the SMS;
• Rectify situations involving below standard performance identified through safety
assurance activities.

CHAPTER 3 P: 3-65
JC Airlines is going to achieve continuous improvement through:

a) Proactive evaluation of facilities, equipment, documentation and procedures
through audits and surveys;
b) Proactive evaluation of the individual's performance, to verify the fulfilment of their
safety responsibilities;
c) Predictive evaluation for identifying operational ascendances and confirming normal
operating procedures;
d) Reactive evaluation in order to verify the effectiveness of the system for control and
mitigation of risks. Example:
• Accidents;
• Incidents;
• Major events investigations.
JC Airlines will use checklists consisting of a comprehensive series of questions, which are
used to ensure that all relevant topics are covered. Checklists should address the following
areas in an organisation:
a) National safety regulatory requirements;
b) JC Airlines’ safety policies and standards;
c) Structure of safety accountabilities;
d) Documentation, such as:
• Safety Management System (SMS) Manual;
• Operational documentation;
e) Safety culture (reactive or proactive);
f) Hazard identification and risk management processes;
g) Safety oversight capabilities (monitoring, inspections, audits, etc);
h) Provisions for assuring safety performance of contractors.
JC Airlines’ techniques for gathering the information on which the audit team’s assessment
will be made include:
• Review of documentation;
• Interviews with staff;
• Observations.
Interviews: This is the JC Airlines’ way to obtain information by asking questions. This
method provides additional information to that available in written material. It also gives the
staff involved an opportunity to explain the system and work practices. Face-to-face
discussions also permit the auditors to make an assessment of the level of understanding
as well as the degree of commitment of the staff of the area to safety management. The
persons to be interviewed should be drawn from a range of management, supervisory and
operational positions. The purpose of audit interviews is to elicit information, not to enter
into discussions.
CHAPTER 3 P: 3-66
Observations: Once the audit activities are completed, the audit team should review all
audit observations and compare them against the relevant regulations and procedures in
order to confirm the correctness of observations noted as nonconformities, deficiencies or
safety shortcomings.

CHAPTER 3 P: 3-67
3.5 CORRECTIVE AND PREVENTIVE ACTION

3.5.1 General
The safety assurance activities include procedures that ensure that corrective actions are
developed in response to findings of reports, studies, surveys, audits, evaluations and so
forth, and to verify their timely and effective implementation. Organizational responsibility
for the development and implementation of corrective actions shall reside with the
operational departments cited in the findings.
The person responsible for the affected functional area is accountable for determining and
implementing appropriate comprehensive corrective actions. The reason for this is twofold:
• The head of organizational unit, that is the person with direct line responsibility for
the affected area, is directly involved in the decision making process. In most cases
he has the knowledge and expertise to recommend effective corrective and
preventative actions and has the authority to assign the appropriate resources
where required;
• The head of organizational unit must assume responsibility for safety within his own
area of responsibility. In this way he is involved in the safety process and is
accountable for issues that arise in his functional area.
The effectiveness of changes resulting from proposal for corrective action identified by the
accident prevention and flight safety programme shall be monitored by the Quality
Assurance Manager, based on the fact that all corrective and preventive actions,
influencing systematic changes regarding the Company, will be delivered to Quality
Assurance Manager by Safety Manager to further action in the scope of Quality Assurance
System.
3.5.2 Corrective Action
Once a safety event report has been investigated and analysed, or a hazard identified, a
safety report outlining the occurrence, and if available, the results of a hazard assessment,
shall be given to the appropriate manager for determination of corrective or preventive
action. The head of organizational unit should develop a corrective action plan, a plan
submitted in response to findings, outlining how the Company proposes to correct the
deficiencies documented in the findings.
Depending on the findings the Corrective Action Plan might include short-term and long-
term corrective actions:
• Short-Term Corrective Action - This action corrects the specific issue specified in
the audit finding and is preliminary to the long-term action that prevents recurrence
of the problem. Short-term corrective action should be completed by the date/time
specified in the corrective action plan;
• Long-Term Corrective Action - Long-term corrective action has two components.
The first element involves identifying the root cause of the problem and indicating
CHAPTER 3 P: 3-68
the measures that will be taken to prevent a recurrence. These measures should
focus on a system change. The second component is a timetable for
implementation of the long term corrective action. Long-term corrective action
should include a proposed completion date.
Some long-term corrective actions may require time perils in excess of the Company's
established acceptable timeframe, for example where major equipment purchases are
involved. Where applicable, the Company should include milestones or progress review
points not exceeding the established timeframe leading up to the proposed completion
date. Where the short-term corrective action taken meets the requirements for long-term
corrective action, this should be stated in the long-term corrective action section on the
corrective action form.
Documented procedures for corrective and preventive action need to be developed by all
departments. All changes to documented procedure resulting from such required actions
shall be recorded and the record retained.
The head of organizational unit shall recommend change or corrective action to the Safety
Department. Manager of appropriate department is responsible for corrective actions
implementation. Safety department shall monitor this implementation.
The effectiveness of changes resulting from proposals for corrective action identified by
the accident and flight safety program shall be monitored by the Quality Assurance
Manager through the quality assurance program.
The procedures for corrective action shall include:

• The effective handling of complaints and reports;
• Investigation of the cause of the nonconformity;
• Determination of the corrective action necessary to eliminate such cause(s);
• The application of contrails to ensure that the corrective action is effective;
3.5.3 Preventive Action
The procedures for preventive action shall include:

• The use of appropriate sources of information which affect the safety process or
activity, to detect, analyse and eliminate potential causes of nonconformity, e.g.
concessions, audit reports, customer complaints;
• Determination of the steps needed to deal with any problems requiring preventive
action;
• The initiation of preventive action, and the application of controls to ensure that it is
effective.

CHAPTER 3 P: 3-69
3.6 SMS AND QMS
Quality Assurance (QA) programme defines and establishes JC Airlines’ quality policy and
objectives. QA ensures that procedures are carried out consistently and in compliance with
applicable requirements, that problems are identified and resolved and that the
organization continuously reviews and improves its procedures, products and services.
The application of QA principles to safety management processes helps ensure that the
requisite system wide safety measures have been taken to support the Company in
achieving its safety objectives. It is the integration of QA principles and concepts into an
SMS under the safety assurance component that assists the Company in ensuring the
necessary standardization of processes to achieve the overarching objective of managing
the safety risks of the consequences of the hazards JC Airlines must confront during its
activities related to the delivery of services.
It is thus essential, to define this relationship from a synergistic rather than an antagonistic
perspective, and the relative contribution of SMS and QMS to the attainment of overall
Company goals and, in particular, to the Company safety goals. SMS and QMS share
many commonalities. They both:
• Have to he planned and managed;
• Depend upon measurement and monitoring;
• Involve every function, process and person in the organisation;
• Strive for continuous improvement.
SMS focuses on human performance, human factors and organisational factors, and
integrates into these, as appropriate, quality management techniques and processes to
contribute to the achievement of safety satisfaction. The objective of SMS is to identify the
safety hazards the Company must confront and that in many cases it generates, during
delivery of services, and to bring the safety risks of the consequences of these hazards
under organizational control. In broad terms, the first imperative of this objective - hazard
identification - is accomplished.
Through the safety risk management component of an SMS, which is based upon safety
management principles and practices, the second imperative - bringing the safety risks
under organisational control is accomplished through the safety assurance component of
an SMS, which is based upon the integration of safety and quality management principles
and practices.
Safety Management System (SMS) differs from Quality Management System (QMS) in
that SMS focuses on the safety, human and organisational aspects of the Company (i.e.
safety satisfaction) while QMS focuses on the products and services of the Company (i.e.
customer satisfaction).
Once commonalities and differences between SMS and QMS have been established, it is
possible to establish a synergistic relationship between both systems. It cannot be

CHAPTER 3 P: 3-70
stressed strongly enough that the relationship is complementary, never adversarial, and it
can be summarized as follows:
• SMS builds partly upon QMS principles;
• SMS should include both safety and quality policies and practices;
• The integration of quality principles, policies and practices, insofar as SMS is
concerned, should be focused towards the support of the management of safety.
Establishing a complementary relationship between SMS and QMS leads to the

complementary contributions of each system to the attainment of the Company's safety
goals:
• SMS results in the design and implementation of organisational processes and
procedures to identify safety hazards and their consequences and bring the
associated safety risks in aviation operations under the control of the Company;
• The integration of QMS into SMS provides a structured approach to monitor that
processes and procedures to identify safety hazards and their consequences, and
bring the associated safety risks in aviation operations under the control of the
Company, function as intended and, when they do not, to improve them;
• SMS focuses on the safety aspects of the Company, QMS focuses on the services
and products of the Company.
• While QMS focuses on conformity, SMS focuses on hazards. Both non-conformities
and hazards can impact safety;
• Both systems enhance safety and are essential and complementary management
tools. You cannot have an effective SMS without applying quality management
principles.

CHAPTER 4 P: 4-1
SAFETY PROMOTION Rev. 00, 10 JAN 2017
4 SAFETY PROMOTION
4.1 GENERAL
An organisational safety effort cannot succeed solely by mandate or strict adherence to

policies. Safety promotion and education helps sets the culture that predisposes both
individual and organisational behaviour, and provides evidence based feedback to support
operating procedures and training. In doing so safety promotion and education fills in the
blank spaces in the organisation’s policies, procedures and processes, providing a sense
of purpose to safety efforts.
Safety promotion encourages a positive safety culture and creates an environment that is
conducive to the achievement of the Company’s safety objectives. A positive safety culture
is characterized by values, attitudes and behaviour that are committed to the
organisation’s safety efforts. This is achieved through the combination of technical
competence that is continually enhanced through training and education, effective
communications and information sharing. Senior management provides the leadership to
promote the safety culture throughout an organization.
JC Airlines regularly communicates its safety objectives, as well as the current status of
any related activities and events. The Company encourages bottom-up communication,
providing an environment that allows senior management to receive open and constructive
feedback from operational personnel.
Safety promotion is necessary to ensure that JC Airlines personnel and its contracted third
party personnel fully understand and trust the SMS policies, procedures, and structure.
This will be achieved by establishing a culture of safety, training all staff in safety
principles, and allowing open communication of safety issues.
The main goal of safety promotion is to create a safety culture that allows the SMS to
succeed. Having a safety culture means that all staff are responsible for safety. Such a
culture is led by top management. Especially in the manner with which they deal with day-
to-day activities, all personnel must fully trust that they will have management support for
decisions made in the interest of safety, while also recognizing that intentional breaches of
safety will not be tolerated. The result is a non-punitive environment that encourages the
identification, reporting, and correction of safety issues.

CHAPTER 4 P: 4-2
4.2 SAFETY TRAINING AND EDUCATION

4.2.1 General
All personnel will be competent to perform Safety Management System (SMS) tasks that
may impact upon the safety of the airline operation. The amount of safety training will be
appropriate to the individual’s responsibility and involvement in the SMS.
SMS Training shall be specified for initial, recurrent and update training, where applicable,
in terms of appropriate education, training and experience. There is a validation process
that measures the effectiveness of training.
SMS training records, including training syllabus, eligibility and requirements, are
documented for all personnel undertaking SMS training.
Training combined with procedures and safety promotion activities are undertaken to
ensure that personnel are trained and competent to perform their SMS duties and are
aware of:
• The safety consequences of their work activities and the benefits of improved
personal performance;
• Their roles and responsibilities within the SMS;
• The potential consequences of departure from standard operating procedures.
The Company’s SMS training is part of the Company’s overall training programme. SMS
awareness is incorporated into the employment and/or indoctrination programme.
4.2.2 Safety Management System Training
JC Airlines’ safety culture is tied to the success of its safety management system training
program. All personnel must understand JC Airlines’ safety philosophy, policies,
procedures and practices. They must understand their roles and responsibilities within that
safety management framework. Safety training should begin with a personnel's initial
indoctrination and continue through his employment. Specific safety management training
should be provided for staffs who occupy positions with particular safety responsibilities.
The training program should ensure that the safety policy and principles of the JC Airlines
are understood and adhered to by all staff, and that all personnel are aware of the safety
responsibilities of their position.
The Safety Manager reviews the job descriptions of all staff, and identifies those positions
that have safety responsibilities. The details of the safety responsibilities shall be added to
the job descriptions.
Once the job descriptions have been updated, the Safety Manager, in conjunction with the
Training Manager, should conduct a training needs analysis, to identify the training that will
be required for each position.

CHAPTER 4 P: 4-3
The level of safety management training required at JC Airlines may vary from general
safety familiarization, to expert level training.
Examples of safety management system training:

• Corporate training for all staff;
• Training aimed at management’s safety responsibilities;
• Training for operational personnel (pilots, cabin crews, maintenance, technicians,
ramp personnel, etc.);
• Training for aviation safety specialists (such as the Safety Manager, etc.).
Once the safety management system is fully implemented, the safety training needs
should be met by incorporating the appropriate safety content into the general training
program for each position.
4.2.3 Initial Safety Management System Training for all Personnel
One of the functions of safety management training is to create awareness of the

objectives of the safety management system of JC Airlines and the importance of
developing a safety culture. All personnel should receive a basic introductory course
covering:
• Basic principles of safety management;
• Corporate safety philosophy, safety policies and safety standards (including
corporate approach to disciplinary action, safety issues, integrated nature of safety
management, risk management decision making, safety culture, etc.);
• Importance of complying with the safety policy and with the procedures that form
part of the safety management system;
• Organisation, roles and responsibilities of staff in relation to safety;
• Corporate safety record, including discussion of areas of systemic weakness;
• Corporate safety goals and objectives;
• Corporate safety management programs (incident reporting systems, Flight Data
monitoring, LOSA, etc.);
• Requirement for ongoing internal assessment of organizational safety performance
(e.g. employee surveys, safety audits and assessments);
• Reporting accidents, incidents and perceived hazards;
• Lines of communications for safety matters;
• Feedback and communication methods for the dissemination of safety information;
• Safety audits and reviews;
• Safety promotion and information dissemination.

CHAPTER 4 P: 4-4
4.2.4 Training for Management Team
It is essential that during the management training for the safety management system and
their responsibilities and accountabilities for safety, the management team understands
the principles on which the safety system is based.
The Accountable Manager shall undergone appropriate SMS familiarization, briefing or

training.
4.2.5 Specialist Safety Training
A number of safety related tasks require specially trained personnel. These include:
• Investigating safety occurrences;
• Monitoring safety performance;
• Performing safety assessments;
• Performing safety audits.
It is important that staff performing these functions receive adequate training in the special
methods and techniques involved. Depending upon the depth of training required and the
level of existing expertise in safety management within JC Airlines, it may be necessary to
obtain assistance from external specialists in order to provide this training.
All Company’s personnel involved in conducting risk mitigation shall be provided with
appropriate risk management training or familiarization.
4.2.6 Safety Training for Operations Personnel
In addition to the corporate indoctrination outlined above, personnel engaged directly in

flight operations (flight crew, cabin crew, maintenance personnel, etc) will require more
specific safety training with respect to:
• Procedures for reporting accidents and incidents;
• Unique hazards faced by operations personnel;
• Procedures for hazard reporting;
• Specific safety initiatives, such as:
- Flight Data Monitoring (FDM) program;
- LOSA program;
• Safety committee(s);
• Seasonal safety hazards and procedures (winter operations, etc);
• Emergency procedures.

CHAPTER 4 P: 4-5
4.2.7 Safety Manager Training
The person selected as the Safety Manager needs to be familiar with all aspects of safety
management, its activities and personnel. These requirements may be met in-house, or
from external courses, however, much of the Safety Manager knowledge will be acquired
by self-education.
Areas where Safety Manager may require formal training include:

• Familiarization with type of operations, routes, etc.;
• Understanding the role of human performances in causing the accidents and their
prevention;
• Operation of safety management systems including risk management;
• Accident and incident investigation;
• Crisis management and emergency response planning;
• Safety promotion;
• Communication skills;
• Computer skills such as word-processing, spreadsheets, and data base
management;
• Specialized training or familiarization (such as Crew Resource Management (CRM),
Flight Data Monitoring (FDM), Line Operations Safety Audits (LOSA)).

CHAPTER 4 P: 4-6
4.3 SAFETY COMMUNICATION
Individual safety training is supplemented by an ongoing two-way communication process

that helps ensure that personnel benefit from safety lessons learned, see the results of
their actions, and continue to improve their understanding of JC Airlines’ Safety
Management System (SMS). When safety recommendations or new procedures are
introduced, the associated underlying safety analysis should also be communicated to the
appropriate staff (flight crew, cabin crew, maintenance personnel, etc.). In addition to
written communications, it is important for employees to witness evidence of the
commitment of top management to safety.
JC Airlines’ safety policies, procedures, newsletters and bulletins alone will not necessarily
bring about the development of a positive safety culture. While it is important that staff be
well informed, it is also important that they see evidence of the commitment of
management to safety. The attitudes and actions of management will therefore be a
significant factor in the promotion of safe work practices and the development of a positive
safety culture.
JC Airlines’ safety promotion activities are equally important during the initial stages of the
implementation of an SMS as well as in the maintenance of safety, as they are the means
by which safety issues are communicated within the Company. These activities shall be
addressed through staff training programs.
In order to propose solutions to identified hazards, staff must be aware of the hazards that
have already been identified and the corrective actions that have already been
implemented. The safety promotion activities and training programs should therefore
address the rationale behind the introduction of new procedures.
JC Airlines’ safety communication aims at:

• Ensuring that all staff is fully aware of the SMS;
• Conveying safety critical information;
• Explaining why particular actions are taken;
• Explaining why safety procedures are introduced or changed;
• Conveying “Nice-to-Know” information.
JC Airlines’ means of safety communication are:

• Spoken words, interviews (e.g. FDM non-compliance with SOP);
• Written word (safety policy and procedures, SMS manual, safety report, safety
bulletins, flight safety notices, SMS bulletins, safety posters, etc.).
JC Airlines and its employees believe that safety communication is an essential foundation
for the development and maintenance of a positive safety culture.

CHAPTER 4 P: 4-7
Flight Safety Notice is issued by Safety Department (Flight Safety Officer or Safety
Manager) whenever a hazard which needs immediate attention has been discovered,
identified and assessed. It provides information of an urgent character and is therefore
distributed to all flight crew members in electronic form and displayed on an easily visible
space in the Flight Dispatch (Operations Control Centre) room. It contains brief description
of the event representing safety hazard with safety recommendations that might indicate
the need for change in operating procedures or standards.
Safety Bulletins are issued by Safety Department periodically in order to keep flight crews
(and cabin crews, as applicable) advised about recent occurrences in the Company or
elsewhere and about safety trends in aviation industry. They may include brief description
of occurrence reports, background explanation, FDM parameters pictures, emphasis of
established OM procedures and safety recommendations. They may also include
particular cases from FDM system or any other topic related to safety of aircraft operation.
SMS Bulletins are issued by the Safety Manager at least once every 12 months and are
used to inform the employees about:
• Critical safety information,
• Outcome of the occurrence/hazard reporting and associated risk analysis,
• Outcomes from Safety/Quality/Security audits,
• Safety/Quality/Security objectives and targets,
• Safety/Quality/Security promotion issues.
JC Airlines’ SMS Manual and related guidance material shall be accessible or

disseminated to all relevant personnel.
JC Airlines participates in safety information sharing with relevant external industry product
and service providers or organizations, including the relevant aviation regulatory
organizations.

CHAPTER 4 P: 4-8
Intentionally Blank

CHAPTER 5 P: 5-1
OCCURRENCE REPORTING FORMS Rev. 00, 10 JAN 2017
5 OCCURRENCE REPORTING FORMS

5.1 AIR SAFETY REPORT (ASR)

CHAPTER 5 P: 5-2
Air Safety Report (ASR) - verso

CHAPTER 5 P: 5-3
5.2 OCCURRENCE REPORT

CHAPTER 5 P: 5-4
5.3 DANGEROUS GOODS OCCURRENCE REPORT

CHAPTER 5 P: 5-5

CHAPTER 5 P: 5-6
5.4 GROUND (INCIDENT/ACCIDENT) DAMAGE REPORT

CHAPTER 5 P: 5-7

CHAPTER 5 P: 5-8
Intentionally Blank

CHAPTER 6 P: 6-1
LOSA OBSERVATION FORM Rev. 00, 10 JAN 2017
6 LOSA OBSERVATION FORM

The LOSA observation form is used to capture multiple aspects of normal operations,
including the operating environment and flight crew performance. It provides categories
and codes to streamline observations and save the observer’s time, but it also requires a
written description of the flight that captures the full context.

CHAPTER 6 P: 6-2

CHAPTER 6 P: 6-3

CHAPTER 6 P: 6-4

CHAPTER 6 P: 6-5

CHAPTER 6 P: 6-6

CHAPTER 6 P: 6-7

CHAPTER 6 P: 6-8

CHAPTER 6 P: 6-9

CHAPTER 6 P: 6-10

CHAPTER 6 P: 6-11

CHAPTER 6 P: 6-12

CHAPTER 6 P: 6-13

CHAPTER 6 P: 6-14
Intentionally Blank

3.SMS Manual PDF

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

3.SMS Manual PDF

Caricato da

Copyright:

Formati disponibili

PRELIMINARY PAGES P: AA-2

AUTHORITY APPROVAL Rev. 00, 10 JAN 2017

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

DISTRIBUTION CONTROL LIST

No. Document Control No. Holder

2. JC/SMS/002 SSCA – Phnom Penh

3. JC/SMS/003 Accountable Manager

4. JC/SMS/004 Safety Manager

5. JC/SMS/005 Quality Assurance Director

6. JC/SMS/006 Flight Safety Officer

7. JC/SMS/007 Company Library

Hard copies shall be printed in A4 or A5 size.

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

RETAIN THIS SHEET UNTIL REPLACED WITH NEW ISSUE

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

RECORD OF AUTHORITY REVISION APPROVALS

Revision No Revision Date Authority Approval Signature Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Revision No Revision Date Authority Approval Signature Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

RECORD OF TEMPORARY REVISIONS

List of Temporary Revisions

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

RECORD OF AUTHORITY TEMPORARY REVISION APPROVALS

Revision No Revision Date Authority Approval Signature Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Reason for issue: New document.

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

LIST OF EFFECTIVE PAGES

Page Revision Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Page Revision Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Page Revision Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Page Revision Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Page Revision Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

Page Revision Date

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

1.9 SMS Documentation ..................................................................................................................... 1-31

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

3.2.7.5 FDM Confidentiality Agreement .................................................................................. 3-41

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

The Safety Management System Manual (SMS Manual) describes JC Cambodia

Documentation system of JC Airlines in general and this manual in particular is reviewed

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

SMS Manual is intended as a guide in planning and operating a comprehensive safety

However, in respect of the maxim that no weakness in a system, especially in aviation,

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

The elements of Safety Program this manual addresses:

SAFETY MANAGEMENT SYSTEM MANUAL JC CAMBODIA INTERNATIONAL AIRLINES

0.3 ORGANIZATION AND IDENTIFICATION