VER 1.
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USHST SMS Gap Analysis Worksheet NOV 2016
SMS Gap Analysis
Version Number: 1.0 Dated: 11/30/2016
Instructions
The following gap analysis template is provided to assist organizations (big or small) who are starting to implement an SMS or would like
to review their current SMS status. This document is based upon the SMS structure and guidance as specified in the International Civil
Aviation Organization (ICAO) Safety Management Manual with minor additions and/or changes. There are other SMS structures/best
practices available, but the ICAO version tends to be the foundation for all standards. Users are encouraged to modify as necessary to
meet their own organization's needs. The information obtained by completing this gap analysis will be useful to your organization for
SMS implementation planning purposes as well as helping senior management understand the scope of necessary resources.
Each SMS Component and its associated Elements are provided on separate worksheets. Select the appropriate tab below to access
the area for review. The SMS Components are (1.0) Safety Policy and Objectives; (2.0) Safety Risk Management; (3.0) Safety
Assurance; (4.0) Safety Promotion.
An answer of "Yes", indicates the organization meets or exceeds the expectation of the question concerned. An answer of "No",
indicates a substantial gap in the existing system with respect to the question’s expectation. An answer of "Partial", indicates that further
enhancement or development work is required to an existing process in order to fully meet the question’s expectations.
Example Entry Below
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
¨ Yes Accountable Executive needs to
þ No No existing policy In the process of
complete and circulate to Safety
1.1-1 Is there a safety policy or statement in place? ¨ Partially drafting original document by the 31-Oct-16 Committee for additional
Accountable Executive. Examples
input/feedback. Finalize, signature and
provided to help draft policy.
distribute to all employees.
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 1.0 - Safety Policy and Objectives
Element 1.1 - Management Commitment and Responsibility
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
¨ Yes
1.1-1 Is there a safety policy or statement in place? ¨ No
¨ Partially
Does the safety policy or statement reflect
¨ Yes
1.1-2 senior management's commitment regarding ¨ No
safety management and Just Culture? ¨ Partially
Is the safety policy or statement appropriate to
¨ Yes
1.1-3 the size, nature and complexity of the ¨ No
organization? ¨ Partially
¨ Yes
Is the safety policy or statement relevant to ¨ No
1.1-4
aviation and total operational safety?
¨ Partially
¨ Yes
Is the safety policy or statement signed by the ¨ No
1.1-5
accountable executive?
¨ Partially
Is the safety policy or statement communicated,
¨ Yes
1.1-6 with visible endorsement, throughout the ¨ No
Organization? ¨ Partially
Is the safety policy or statement periodically
¨ Yes
1.1-7 reviewed to ensure it remains relevant and ¨ No
appropriate to the Organization? ¨ Partially
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 1.0 - Safety Policy and Objectives
Element 1.2 - Safety Accountabilities
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Has the Organization identified an accountable
¨ Yes
executive who, irrespective of other functions, ¨ No
1.2-1
shall have ultimate responsibility and ¨ Partially
accountability, on behalf of the Organization, for
the implementation and maintenance of the
SMS?
Does the accountable executive have full control ¨ Yes
of the financial and human resources required ¨ No
1.2-2
for the operations authorized to be conducted ¨ Partially
under the operations certificate?
Does the Accountable Executive have final
¨ Yes
1.2-3 authority over all aviation activities of his ¨ No
organization? ¨ Partially
Has the Organization identified and documented ¨ Yes
1.2-4
the safety accountabilities of management as ¨ No
well as operational personnel, with respect to ¨ Partially
the SMS?
Is there a safety committee or review board for
¨ Yes
1.2-5 the purpose of reviewing SMS and safety ¨ No
performance? ¨ Partially
Is the safety committee chaired by the ¨ Yes
1.2-6
accountable executive or by an appropriately ¨ No
assigned deputy, duly substantiated in the SMS ¨ Partially
manual?
Does the safety committee include relevant
¨ Yes
1.2-7 operational or departmental heads as ¨ No
applicable? ¨ Partially
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 1.0 - Safety Policy and Objectives
Element 1.2 - Safety Accountabilities
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Are there safety action groups that work in
¨ Yes
1.2-8 conjunction with the safety committee ¨ No
(especially for large/complex organizations)? ¨ Partially
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 1.0 - Safety Policy and Objectives
Element 1.3 - Appointment of Key Safety Personnel
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Has the Organization appointed a qualified
¨ Yes
1.3-1 person to manage and oversee the day-to-day ¨ No
operation of the SMS? ¨ Partially
Does the qualified person have direct access or ¨ Yes
1.3-2
reporting to the accountable executive ¨ No
concerning the implementation and operation of ¨ Partially
the SMS?
Does the manager responsible for administering
¨ Yes
1.3-3 the SMS hold other responsibilities that may ¨ No
conflict or impair his role as SMS manager. ¨ Partially
Is the SMS manager’s position a senior ¨ Yes
1.3-4
management position not lower than or ¨ No
subservient to other operational or production ¨ Partially
positions?
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 1.0 - Safety Policy and Objectives
Element 1.4 - Coordination of Emergency Response Planning
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Does the Organization have an emergency
¨ Yes
1.4-1 response/contingency plan appropriate to the ¨ No
size, nature and complexity of the organization? ¨ Partially
Does the emergency/contingency plan address ¨ Yes
1.4-2
all possible or likely emergency/crisis scenarios ¨ No
relating to the organization’s aviation product or ¨ Partially
service deliveries?
Does the ERP include procedures for the ¨ Yes
1.4-3
continuing safe production, delivery or support ¨ No
of its aviation products or services during such ¨ Partially
emergencies or contingencies?
¨ Yes
Is there a plan and record for drills or exercises ¨ No
1.4-4
with respect to the ERP?
¨ Partially
Does the ERP address the necessary ¨ Yes
coordination of its emergency ¨ No
1.4-5 response/contingency procedures with the ¨ Partially
emergency/response contingency procedures of
other organizations where applicable?
Does Organization have a process to distribute ¨ Yes
1.4-6
and communicate the ERP to all relevant ¨ No
personnel, including relevant external ¨ Partially
organizations?
Is there a procedure for periodic review of the
¨ Yes
1.4-7 ERP to ensure its continuing relevance and ¨ No
effectiveness? ¨ Partially
Note: Organizations should consider a contingency for recovering aircraft after release by the investigating agency.
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 1.0 - Safety Policy and Objectives
Element 1.5 - SMS Documentation
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Is there a top-level SMS summary or exposition ¨ Yes
1.5-1
document which is approved by the accountable ¨ No
manager and accepted by the Regulatory ¨ Partially
Authority?
Does the SMS documentation address the
¨ Yes
1.5-2 organization’s SMS and its associated ¨ No
components and elements? ¨ Partially
¨ Yes
Is Organization SMS framework in alignment ¨ No
1.5-3
with the regulatory SMS framework?
¨ Partially
Does Organization maintain a record of relevant
¨ Yes
1.5-4 supporting documentation pertinent to the ¨ No
implementation and operation of the SMS? ¨ Partially
Does Organization have an SMS ¨ Yes
implementation plan to establish its SMS ¨ No
1.5-5
implementation process, including specific tasks ¨ Partially
and their relevant implementation milestones?
Does the SMS implementation plan address the ¨ Yes
1.5-6
coordination between the service provider’s ¨ No
SMS and the SMS of external organizations ¨ Partially
where applicable?
¨ Yes
Is the SMS implementation plan endorsed by ¨ No
1.5-7
the accountable executive?
¨ Partially
Examples of SMS Documentation: SMS Manual, Accountable Executive Safety Policy, Hazard/Occurrence Event Report, Hazard Register/Log, Risk Profile,
Management of Change form, Pre-Flight Risk Analysis Tool, Ground Risk Analysis Tool, Internal Evaluation/Audit Checklists, Risk Assessment Matrix, Key Performance
Indicators, etc.
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 2.0 - Safety Risk Management
Element 2.1 - Hazard Identification
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
¨ Yes
Is there a process for voluntary hazards/threats ¨ No
2.1-1
reporting by all employees?
¨ Partially
Is the voluntary hazard/threats reporting simple, ¨ Yes
available to all personnel in the organization, ¨ No
2.1-2 commensurate with the size of the service ¨ Partially
provider and the have the ability to be
anonymous when desired?
Does Organization's Safety Data Collection and ¨ Yes
2.1-3
Processing Systems (SDCPS) include ¨ No
procedures for incident/accident reporting by all ¨ Partially
personnel?
Is incident/accident reporting simple, accessible ¨ Yes
to all personnel in the organization, ¨ No
2.1-4 commensurate with the size of the service ¨ Partially
provider and the have the ability to be
anonymous when desired?
¨ Yes
Does Organization have procedures for ¨ No
2.1-5
investigation of all reported incident/accidents?
¨ Partially
Are there procedures to ensure that ¨ Yes
hazards/threats identified or uncovered during ¨ No
incident/accident investigation processes are ¨ Partially
appropriately accounted for and integrated into
2.1-6 the organization’s hazard collection and risk
mitigation procedure? Are these
hazards/threats as well as their identified
mitigation effectively communicated to all
personnel?
Are there procedures to review hazards/threats
¨ Yes
2.1-7 from relevant industry reports for follow-up ¨ No
actions or risk evaluation where applicable? ¨ Partially
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 2.0 - Safety Risk Management
Element 2.2 - Safety Risk Assessment and Mitigation
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Is there a documented hazard identification and
¨ Yes
2.2-1 risk mitigation (HIRM) procedure involving the ¨ No
use of objective risk analysis tools? ¨ Partially
Is the risk assessment reports approved by
¨ Yes
2.2-2 departmental managers or at a higher level ¨ No
where appropriate? ¨ Partially
¨ Yes
Is there a procedure for periodic review of ¨ No
2.2-3
existing risk mitigation records?
¨ Partially
Is there a procedure to account for mitigation
¨ Yes
2.2-4 actions whenever unacceptable risk levels are ¨ No
identified? ¨ Partially
¨ Yes
Is there a procedure to prioritize identified ¨ No
2.2-5
hazards for risk mitigation actions?
¨ Partially
Is there a program for systematic and ¨ Yes
progressive review of all aviation safety-related ¨ No
2.2-6 operations, processes, facilities and equipment ¨ Partially
subject to the HIRM process as identified by the
organization?
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 3.0 - Safety Assurance
Element 3.1 - Safety Performance Monitoring and Measurement
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Are there identified safety performance ¨ Yes
3.1-1
indicators for measuring and monitoring the ¨ No
safety performance of the organization’s aviation ¨ Partially
activities?
Are the safety performance indicators relevant ¨ Yes
3.1-2
to the organization’s safety policy as well as ¨ No
management’s high-level safety ¨ Partially
objectives/goals?
Do the safety performance indicators include ¨ Yes
3.1-3
alert/target settings to define unacceptable ¨ No
performance regions and planned improvement ¨ Partially
goals?
Is the setting of alert levels or out-of-control
¨ Yes
3.1-4 criteria based on objective safety metrics ¨ No
principles? ¨ Partially
Do the safety performance indicators include ¨ Yes
quantitative monitoring of high-consequence ¨ No
3.1-5
safety outcomes (e.g. accident and serious ¨ Partially
incident rates) as well as lower-consequence
events (e.g. rate of non-compliance,
deviations)?
Are safety performance indicators and their ¨ Yes
3.1-6
associated performance settings developed in ¨ No
consultation with, and subject to, the civil ¨ Partially
aviation authority’s agreement?
Is there a procedure for corrective or follow-up ¨ Yes
action to be taken when targets are not ¨ No
3.1-7
achieved and alert levels are exceeded/
breached?
¨ Partially
¨ Yes
Are the safety performance indicators ¨ No
3.1-8
periodically reviewed?
¨ Partially
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 3.0 - Safety Assurance
Element 3.2 - The Management of Change
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Is there a procedure for review of relevant ¨ Yes
existing aviation safety-related facilities and ¨ No
3.2-1 equipment (including HIRM records) whenever ¨ Partially
there are pertinent changes to those facilities or
equipment?
Is there a procedure for review of relevant ¨ Yes
existing aviation safety-related operations and ¨ No
3.2-2 processes (including any HIRM records) ¨ Partially
whenever there are pertinent changes to those
operations or processes?
Is there a procedure for review of new aviation
¨ Yes
3.2-3 safety-related operations and processes for ¨ No
hazards/risks before they are commissioned? ¨ Partially
Is there a procedure for review of relevant ¨ Yes
existing facilities, equipment, operations or ¨ No
3.2-4
processes (including HIRM records) whenever ¨ Partially
there are pertinent changes external to the
organization such as regulatory/industry
standards, best practices or technology?
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 3.0 - Safety Assurance
Element 3.3 - Continuous Improvement of the SMS
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
¨ Yes
Is there a procedure for periodic internal ¨ No
3.3-1
audit/assessment of the SMS?
¨ Partially
¨ Yes
Is there a current internal SMS ¨ No
3.3-2
audit/assessment plan?
¨ Partially
¨ Yes
Does the SMS audit plan include the sampling ¨ No
3.3-3
of completed/existing safety risk assessments?
¨ Partially
Does the SMS audit plan include the sampling ¨ Yes
of safety performance indicators for data ¨ No
3.3-4
currency and their target/alert settings
performance?
¨ Partially
Does the SMS audit plan cover the SMS
¨ Yes
3.3-5 interface with subcontractors or customers ¨ No
where applicable? ¨ Partially
Is there a process for SMS audit/assessment ¨ Yes
3.3-6
reports to be submitted or highlighted for the ¨ No
accountable manager’s attention where ¨ Partially
appropriate.
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 4.0 - Safety Promotion
Element 4.1 - Training and Education
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Is there a program to provide SMS
¨ Yes
4.1-1 training/familiarization to personnel involved in ¨ No
the implementation or operation of the SMS? ¨ Partially
Has the accountable executive undergone
¨ Yes
4.1-2 appropriate SMS familiarization, briefing or ¨ No
training? ¨ Partially
Are personnel involved in conducting risk
¨ Yes
4.1-3 mitigation provided with appropriate risk ¨ No
management training or familiarization? ¨ Partially
¨ Yes
Is there evidence of organization-wide SMS ¨ No
4.1-4
education or awareness efforts?
¨ Partially
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USHST SMS Gap Analysis Worksheet NOV 2016
Component 4.0 - Safety Promotion
Element 4.2 - Safety Communication
Element Status of Implementation / Target
Aspect or Item to be Reviewed Answer Action/Task Required to Fill Gap
No. Description of Gap Date
Does the Organization participate in sharing ¨ Yes
safety information with relevant external industry ¨ No
4.2-1 product and service providers or organizations, ¨ Partially
including the relevant aviation regulatory
organizations?
Is there evidence of a safety (SMS) publication,
¨ Yes
4.2-2 circular or channel for communicating safety ¨ No
(SMS) matters to employees? ¨ Partially
Are the Organization's SMS manual and related
¨ Yes
4.2-3 guidance material accessible or disseminated to ¨ No
all relevant personnel? ¨ Partially
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