Conducting a Safety
Management Gap Analysis
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This user guide provides Certificate Holders with guidance on completing a safety management gap analysis, for internal use and for submission to BDCA as part of Phase I of BDCA’s Safety
Management System (SMS) Acceptance process. It allows companies to compare their existing management processes against those needed for an effective SMS.
The template found in the Appendix also forms the basis of the Certificate Holder’s plan to implement their SMS, and is sent to BDCA with the rest of the material for Phase I acceptance.
Following Phase I acceptance, the table can be used internally to measure progress in implementing the SMS.
The guide assumes that the company completing a gap analysis is in the process of establishing an SMS but does not yet have a formal SMS in place. If your company already has a formal SMS in place, one that has been accepted by a recognized body (TCCA, IBAC or
BDCA), then the document 1-SO-06 SMS Self-Assessment Guide (also on the BDCA website) will provide you with more useful feedback regarding the state of safety management within your organization.
Operating experience has identified that poorly-managed organizational change is a source of hazards in the aviation industry. Because implementing an SMS is a major task for most organizations, it is essential that a thorough plan be put in place to manage this potentially significant change. Conducting a formal Gap Analysis to identify variances between current processes and the requirements under OTARs enables companies to develop such a plan.
When completing a Gap Analysis and developing an SMS implementation plan, it is important to understand the concepts of hazard, risk, system safety deficiency (SSD) and mitigation. Refer to document 1-SO-02 Key Definitions for SMS for BDCA’s safety management definitions.
The purpose of an SMS Gap Analysis is to identi fy differences between a company’s existing processes and practices and the requirements (both regulated and performance based) of an effective SMS, thus enabling an SMS implementation plan to be created.
The gap analysis is completed by assigning a team comprising between one and four individuals to gather evidence and complete the gap analysis tables. The gap analysis needs to be conducted by one or more persons who have detailed knowledge of what is supposed to exist, and what actually exists, or who have the ability to gather this information (e.g., people

Conducting a Safety
Management Gap Analysis
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Page 2 of 2 who are trained in auditing or investigation). Once the necessary information has been collected from the whole organisation, the person(s) conducting the analysis identify the common gaps that exist (for example, the team might identify a lack of formal, explicit safety-risk management throughout the company).
Sometimes a gap analysis identifies not just gaps in proactive safety management, but also performance deficiencies in current processes or procedures. For example, the company might have a company-wide document control process, but the analysis could identify that one branch within the company is not applying it effectively, resulting in several out of date documents. It is often best to write a small conclusion to highlight these types of high level observations, so they can be considered when building the implementation plan.
The report of the gap analysis need not be complicated. It should contain sufficient information to:

Explain what was done, when and by whom; and

Identify current strengths and weaknesses in safety management compared to the future requirements of an SMS − in the current management structure [i.e., identifying the presence (or lack of presence) of documented policies and procedures], and in the functionality (i.e., determining how well existing management processes are working in practice).
The table in Appendix A can be used to guide the completion of the gap analysis and report.
Use the Evidence/Comments column to record details on the present status of each item or activity, or to record remedial actions that are required to meet the requirement. The completed gap analysis tables are then used inform the plan to implement the SMS. Additional guidance on developing an implementation plan is found in document 1-SO-08 Industry Guidance for
SMS Acceptance, available on BDCA’s website.
For more information on the requirements for a customized SMS, refer to ASSI’s OTAC titled
Safety Management Systems . See also the OTAC 'Documenting the SMS' , available on ASSI’s website ( www.airsafety.aero
).

Appendix A
Safety Management
Gap Analysis Template
Date gap analysis completed: (Month DD, YYYY)
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Gap Analysis Completed by:
(List personnel responsible for completing the gap analysis, by title)
Description of Gap Analysis Process:
(Briefly describe the steps undertaken to complete the Gap Analysis)
To complete the Gap Analysis, gather information to answer each of the questions in the requirement column. Questions for which the answer is “No” indicate a gap in the management structure . Questions for which the answer is “Yes” but evidence suggests that the intent of the requirement is not always being met indicate a gap in performance. Both types of gap must be addresse d in the company’s SMS Implementation Plan.
Yes/No Evidence / Comments Requirement
Is there a formal process to tie all aspects of the operation (e.g., the management of operations and technical systems, finance, human resources) together so that safety performance is linked to business performance?
Has the Chief Executive or the
Accountable Manager (i.e., the manager responsible for the organization’s financial and business decisions) signed a commitment that he or she is responsible for and will implement a safety management system?

Appendix A
Safety Management
Gap Analysis Template
Requirement
Is there a written Safety Policy signed by the Chief Executive or Accountable
Manager?
Does the Safety Policy include or refer to objectives related to the continuous improvement of the organisation’s overall safety performance?
Are the roles and responsibilities of all personnel defined and documented?
Have all personnel been educated on their roles and responsibilities related to safety management (e.g., how to recognize and report hazards, how to recognize and address fatigue, etc.)?
Is there a prioritised list of the systemic organizational, operational or technical safety-risk management challenges that the service provider faces (sometimes ca lled a ‘risk profile’)?
Are processes in place to proactively report identified safety hazards and assess associated safety-risks arising in day-to-day work?
Are processes in place to report and analyse incidents to identify safety hazards and assess associated safety-risks?
Are processes in place to proactively identify and manage potential safety hazards and risks that result from change?
Are processes in place to develop and implement remedial actions, and to track the completion of same?
Are processes in place to communicate the results of safety management activities (e.g., risk assessments, remedial actions taken) to staff?
Are there provisions for continuous monitoring and regular assessment of the company’s safety performance?
Yes/No
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Evidence / Comments

Appendix A
Safety Management
Gap Analysis Template
Requirement
Are processes in place to measure the performance of the company’s management system(s)?
Are processes in place to identify applicable requirements, regulations and standards, and to ensure compliance with same?
Are processes in place to ensure that technical manuals, checklists and other documentation are appropriately maintained and incorporate the latest
Amendments?
Is there a training program in place to ensure that staff are proficient and competent in their duties?
Are processes in place to ensure that the training programme functions effectively to maintain staff proficiency and competence?
Is there a comprehensive Emergency
Response Plan?
Yes/No
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Evidence / Comments