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inspections and safety audits, etc.;
c) carrying out enforcement actions as necessary;
d) monitoring technological developments and best industry practices with a view to improving the
State’s aviation system performance;
e) maintaining a system of aviation records, including licences and certificates, infractions, and
reported accidents and incidents;
f) conducting analyses of safety trends, including accident/incident data, and service difficulty reports;
and
g) promoting safety through the dissemination of specific safety materials, conducting safety seminars,
etc.
3.3.3 Many States delegate responsibility for the investigation of accidents and serious incidents
(pursuant to Annex 13) to their CAAs. However, this practice raises a potential conflict of interest whereby
the investigators may be required to report on shortcomings in the State’s safety oversight performance
(perhaps even their own performance as regulators). Increasingly, States are creating specialist
investigative agencies that are independent of the regulatory authorities.
3-4 Safety Management Manual (SMM)
3.4 STATE SAFETY PERFORMANCE
3.4.1 ICAO’s Universal Safety Oversight Audit Programme has identified fundamental weaknesses in
the safety programmes of many States, resulting in significant differences in safety standards around the
globe. Notwithstanding the obligations of Contracting States to fulfil the requirements of ICAO SARPs,
States should be concerned with the safety performance of their national aviation system. The following are
some indicators that a State’s safety programme may be deficient:
a) inadequate governing legislation and regulations (incomplete, out of date, etc.);
b) potential conflicts of interest (regulator versus service provider, educator versus enforcer, regulator
investigating occurrences involving failures by the regulator, etc.);
c) inadequate civil aviation infrastructure and systems (navigation and communication aids,
aerodromes, airspace management, etc.);
d) inadequate (incomplete, out-of-date, inconsistent) fulfilment of regulatory functions such as
licensing, surveillance and enforcement (due to resource limitations, political situation, state of
national emergency, etc.);
e) inadequate resources and organization for the magnitude and complexity of regulatory requirements
(shortages in trained and competent personnel, administrative capacity, information technology,
etc.);
f) instability and uncertainty within the CAA compromising quality and timeliness of regulatory
performance (staff morale, political interference, resource limitations, etc.);
g) absence of formal safety programmes (voluntary incident reporting programme, regulatory safety
audits, etc.); and
h) stagnation in safety thinking (rising occurrence rates, weak national safety culture, reluctance to
embrace proven best practices, etc.).
3.4.2 On the other hand, having the following elements in a State’s safety programme suggests that
the programme is providing a sound basis for preserving the desired margins of safety:
a) the administrative machinery for coordinating and integrating all aspects of the State’s safety
programme into a coherent whole;
b) performance monitoring for all State safety functions (licensing, certification, enforcement, etc.);
c) provision of State hazard identification programmes (mandatory occurrence reporting, voluntary
(non-punitive) incident reporting, service difficulty reporting, etc.);
d) competent accident and incident investigation capabilities (independent from regulatory authority);
e) risk-based resource allocations for all regulatory functions (proactively targeting regulatory attention
on known areas of high risk);
f) active and passive safety promotion programmes to assist operators and to make safety information
broadly accessible (including safety databases, trend analysis, monitoring of best industry practices,
etc.);
Chapter 3. State Safety Programme 3-5
g) national safety monitoring programmes (trend monitoring and analysis, safety inspections, incident
investigations and safety surveillance); and
h) regular regulatory safety audits to ensure compliance by all operators and service providers.
___________________
4-1
Chapter 4
UNDERSTANDING SAFETY
4.1 GENERAL
4.1.1 As discussed in Chapter 1, safety is a condition in which the risk of harm or damage is limited to
an acceptable level. The safety hazards creating risk may become evident after an obvious breach of safety,
such as an accident or incident, or they may be proactively identified through formal safety management
programmes before an actual safety event occurs. Having identified a safety hazard, the associated risks
　
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