BCAA Procedure Manual SMS INTERFACE for ATO (SIA)

Transcription

1 BCAA Procedure Manual SMS INTERFACE for ATO (SIA) BCAA Guidance Material for use of the Open-source Microsoft Excel Interface for SMS (Safety Management System) for ATO (EASA Approved Training Organizations)

2 0.1. Table of Contents: 0.1. Table of content List of Effective Pages Validity of the document Record of revision Legal disclaimer Intro Abbreviations... 8 CHAPTER 1: Legal basis CHAPTER 2: General conditions CHAPTER 3: Concept Different TAB s BCAA requirements in the use of SIA CHAPTER 4: Getting started with SIA STEP 1: Annual Risk Assessment STEP 2: Follow-up of occurrences STEP 3: Safety Meeting STEP 4: Follow-up STEP 5: Safety Planning STEP 6: Safety briefing & promotion STEP 7: Management of change STEP 8: Use of SIA as a Management tool CHAPTER 5: Feedback of SIA to BCAA BCAA Procedure Manual SIA Revision original 2

3 0.2. List of Effective Pages: Page Date Revision Latest Revision 1 01/01/2017 ORIGINAL * 2 01/01/2017 ORIGINAL * 3 01/01/2017 ORIGINAL * 4 01/01/2017 ORIGINAL * 5 01/01/2017 ORIGINAL * 6 01/01/2017 ORIGINAL * 7 01/01/2017 ORIGINAL * 8 01/01/2017 ORIGINAL * 9 01/01/2017 ORIGINAL * 10 01/01/2017 ORIGINAL * 11 01/01/2017 ORIGINAL * 12 01/01/2017 ORIGINAL * 13 01/01/2017 ORIGINAL * 14 01/01/2017 ORIGINAL * 15 01/01/2017 ORIGINAL * 16 01/01/2017 ORIGINAL * 17 01/01/2017 ORIGINAL * 18 01/01/2017 ORIGINAL * 19 01/01/2017 ORIGINAL * 20 N/A N/A * 21 N/A N/A * 22 N/A N/A * 23 N/A N/A * 24 N/A N/A * 25 N/A N/A * 26 N/A N/A * 27 N/A N/A * 28 N/A N/A * 29 N/A N/A * 30 N/A N/A * 31 N/A N/A * 32 N/A N/A * 33 N/A N/A * 34 N/A N/A * 35 N/A N/A * 36 N/A N/A * 37 N/A N/A * 38 N/A N/A * 39 N/A N/A * 40 N/A N/A * BCAA Procedure Manual SIA Revision original 3

4 0.3. Validity of the document: Prepared by Name Signature Date Responsible for the document Jelle Vanderhaeghe 01/01/2017 Approved by Name Signature Date Head of Licensing Directorate Philippe D homme Head of Training Department Olivier Grisel Seal of the authority BCAA Procedure Manual SIA Revision original 4

5 0.4. Record of revisions: Revision number Revision date: Description of change: Pages: Performed by: ORIGINAL 01/01/2017 Composition of original document ALL Jelle Vanderhaeghe 0.5. Legal disclaimer: This document is composed to provide guidelines to the users of the BCAA SMS Interface for ATO (SIA). There is no legal obligation to follow these guidelines, but all explained in this document are best practices to ensure a minimum level of SMS in the organizations active in pilot training in Belgian civil aviation. All other training organizations (non-belgian, or non-european) are free to use the interface, as long as it is approved by their respective Competent Authorities of Oversight. This tool is aimed at enhancing aviation safety and is offered for free to anyone who want to use it for that purpose. BCAA accepts no liability, or responsibility whatsoever in case of air accidents or incidents, caused by, or involving users of this open-source interface. BCAA Procedure Manual SIA Revision original 5

6 BELGIAN CIVIL AVIATION AUTHORITY 0.6. Intro: When inquiring crashes involving a certain type of aircraft of the 1940 ies and fifties, like for example the Lockheed Constellation, the lists and image one can find on the internet, are endless. The number of spectacular, but also lethal accidents that occurred with this new form of common transport, via the air, just after the Second World War, made ICAO (the International Civil Aviation Organization, under the UN) to instate Annex 13 to the Chicago Convention, on Air Accident Investigation, imposing all Member States to inquire each Air Accident, or Incident in a standardized fashion. Ever since this approach a lot has been learned from each Air Accident: From the Tenerife collision of 2 Jumbo Jets in 1977 resulted in the implementation of ground radar, the PF/PM (Pilot Flying/Pilot Monitoring) & CRM-concept, as well as more strict adherence to standard ICAO R/T-phraseology, just to name one example. This reactive approach to Air Accidents and Incidents has significantly reduced the numbers of Air Accidents but unfortunately the improvements are usually only established after a great loss of life (the example above lead to the deaths of 583 people). Such an approach was common in aviation until a few years ago, but would be unimaginable in other, but similar higher risk environments like the Nuclear and the Pharmaceutical Industry, where the slightest mistake can cause a multitude of casualties. For years a more proactive approach towards safety was applied in those domains. When investigating accidents (not only in aviation) a common trait is that the signs where there already way before the accident occurred. A number of hazards that were previously avoided successfully when they occurred individually, may lead to a catastrophe, when they occur in a combined manner, on a less fortunate day. Safety Management is based on identifying all possible hazards and indicators that someday could contribute to an Air Incident, of Accident and manage them to avoid incidents and accidents. With ICAO ANNEX 18 (SMS/SSP) the civil aviation industry adopted this, more pro-active approach to safety. Rather than awaiting accidents, both the Competent Authorities and Organizations are now legally obliged to deal with Aviation Safety, identify and mitigate hazards, follow-up occurrences and improve their systems, procedures and training. It also requires greater involvement form the Competent Authorities in the flying community in a less punitive, but more understanding/enabling role ( Just Culture ), free of blame, not to revoke/limit/suspend licenses, but so all the aviation community can learn from honest mistakes, or involuntary occurrences that happened to pilots. BCAA Procedure Manual SIA Revision original 6

7 In the light of European Air Crew Regulations (EU Regulations 1178/2011 and its amendments), more commonly known as PART-FCL, and the EU Regulations 376/2012 & 1018/2015, regulating occurrence reporting in the European Airspace, the set-up and Management of a Safety System has become mandatory for all EASA ATO (Approved Training Organizations). As the principles of SMS were also new to BCAA in 2011, it was difficult to set-up guidelines right away regarding SMS (implementation of EASA Air Crew Regulations needed our focus elsewhere). Having seen a lot of noble initiatives and a lot of hard work and investments by ATO and other organizations, BCAA Training Department observed the following systematically, during SMS-audits: 1. Almost never was the full-scope of SMS realized. A fully developed SMS is a variety of activities: proactive hazard identification and mitigation, occurrence follow-up and reporting, optimizing procedures and systems, safety promotion and providing feedback to stimulate the reporting culture, managing the changes to the organization, etc. 2. Although the basic principles are quite clear, every organization set-up their own system, with own philosophy and highlights, leading to A. Loss of standardization and B. Inability to compare, or obtain any kind of national statistics. 3. Use of a multitude of applications (Microsoft Excel for the hazard register, written documents to report the occurrences, Word for the reports of the Safety meetings, PowerPoint for the presentations, etc.), leading to a very diffuse SMS within each organization. In an effort to standardize and cover the full scope of SMS in one interface, among BCAA Approved ATO, BCAA has commissioned the development of SIA (SMS Interface for ATO). We hope this may be a useful tool for all its users and are looking forward to your feedback and suggestions for improvement! Many safe and happy landings in 2017! Jelle Vanderhaeghe Safety Coordinator BCAA Licensing Directorate BCAA Procedure Manual SIA Revision original 7

8 0.7. Abbreviations: ATO: EASA ICAO SIA: SMS: EASA Approved Training Organization, in accordance with EU 1178/2011 and EU 290/2012 (and their amendments), PART-ORA.ATO.GEN: Any organization providing training for pilot licenses and associated ratings and certificates. European Aviation Safety Agency, a European institute responsible for European civil aviation. International Civil Aviation Organization, a specialized United Nations Agency, responsible for civil aviation. SMS Interface for ATO. The composition was commissioned by BCAA and is freely offered to all Belgian/European (and if useful for) Third Country ATO (Approved Training Organizations). Safety Management System. Legal requirement for all organizations active in civil aviation, of ICAO Member States, since 2012, in accordance with ICAO ANNEX 18 (SMS/SSP) BCAA Procedure Manual SIA Revision original 8

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10 CHAPTER 1: Legal basis 1.1. EASA ORA.200 GEN - MANAGEMENT SYSTEM (a) The organization shall establish, implement and maintain a management system that includes: (3) the identification of aviation safety hazards entailed by the activities of the organization, their evaluation and the management of associated risks, including taking actions to mitigate the risk and verify their effectiveness; (b) The management system shall correspond to the size of the organization and the nature and complexity of its activities, taking into account the hazards and associated risks inherent in these activities. AMC1 ORA.GEN.200(a)(1);(2);(3);(5) Management system NON-COMPLEX ORGANISATIONS - GENERAL (a) Safety risk management may be performed using hazard checklists or similar risk management tools or processes, which are integrated into the activities of the organization. (b) The organization should manage safety risks related to a change. The management of change should be a documented process to identify external and internal change that may have an adverse effect on safety. It should make use of the organization s existing hazard identification, risk assessment and mitigation processes. BCAA Procedure Manual SIA Revision original 10

11 CHAPTER 2: GENERAL CONDITIONS: SIA (SMS Interface for ATO) is a BCAA commissioned open source Microsoft Excel tool, destined for practical, daily Safety Management, within EASA ATO. BCAA holds the copyright of SIA and the Interface has been registered with the Belgian Patent Bureau (DIE Dienst voor Intellectuele Eigendom / OPRI Office belge de Propriété Intellectuelle), part of the Belgian Federal Public Service Economy. SIA is made available FREE OF CHARGE to the whole aviation community, for the benefit of aviation safety. All ATO worldwide are allowed to use SIA and provide BCAA with suggestions for improvement. All companies or persons, Belgian or foreign, who use SIA and its contents to charge money for it to third parties, will be prosecuted by BCAA for copyright infringement. SIA is not to be modified by its individual Belgian users: it will be used for comparison purposes and drawing statistics on a National level (and contribute to the European level), after de-identification of the data. Modifications by individual users will render the statistics unusable, so individual modifications and individual creativity should be avoided. Multiple cells are password protected and not to be modified. Users are requested not to (try to) bypass the password protected cells. Use of SIA is not legally obliged. BCAA approved ATO are strongly recommended to use SIA for standardization among ATO and ease of oversight/comparison/exchange of safety data. ATO who chose not to implement and use SIA, should demonstrate equivalent capabilities of their own interface, at their own expense and responsibility, however. With the implementation of SIA, ATO are estimated to be compliant with the implementation phase of SMS. The proper use (follow-up of hazards and occurrences) is the sole responsibility of the ATO. BCAA accepts no responsibility for accidents/incidents/occurrences, or findings of non-conformity against national, European, or International (aviation) legislation, while using SIA. BCAA Procedure Manual SIA Revision original 11

12 CHAPTER 3: CONCEPT: 3.1. Different TAB s: SIA is destined to cover the full scope of SMS (status of International and EU-legislation anno 2017) for civil aviation, in accordance with EU 1178/2011 and its updates, in 1 Excel-sheet ( Microsoft), distributed over 11 numbered TABs: 1. Annual Risk Assessment (TAB 1), or Hazard Register : to be assessed by each ATO, considering their own particular situation (airfield, management, history, type of training and aircraft, etc.) and reviewed 1x per year, in the light of reported occurrences, the year before. 2. Risk Assessment Matrix (TAB 2) - FOR INFO ONLY: Overview of the Probability of occurrence vs Severity of the outcome (for info/clarification to the user), detailing the criteria by which TAB 1 (the Annual Risk Assessment) is composed and the assessment of Risks/hazards should be performed by the Safety Meeting. 3. Occurrence Follow-up 2016 (TAB 3): Each occurrence is to be encoded in TAB 3 in SIA, in a standardized fashion, by the Safety Manager of the ATO. Follow-up must be performed within the same TAB, on the same line, from the initial reporting of the occurrence, until mitigating measures have been decided upon and implemented (to reduce the probability of the occurrence and/or severity of the outcome, or to reduce the risk of reoccurrence). This TAB may also be used as the report (minutes of meeting) of the ATO safety meeting(s) and also serves as follow-up sheet for the Safety actions decided upon. 4. Occurrence Identification (TAB 4) - FOR INFO ONLY: Overview of all occurrences estimated relevant for ATO and their identifiers, as applied in the European occurrence database ECCAIRS. 5. Occurrence Classification (TAB 5) FOR INFO ONLY: In TAB3 the Safety Manager, or the Safety Meeting is requested to quantify the reported occurrence on a severity scale, ranging between Insignificant and catastrophic 6. Visual representation (TAB 6) - FOR INFO ONLY: Automatically generated visual representation of a preselected set of parameter as introduced the Occurrence Follow-up sheet (TAB 3), for Management & feedback purposes, to visually represent the Safety statistics of the ATO. 7. Safety Plan 2018 (TAB 7): Based on the analysis of the occurrences in the preceding year (2017), the ATO Safety Manager and Safety Meeting should compose a safety plan for the next year (2018). An update/overhaul of SIA for 2018 is planned, so no plans are yet included for beyond BCAA Procedure Manual SIA Revision original 12

13 8. Safety briefings performed (TAB 7): Depending on the Safety plan 2017 composed by the ATO (as discussed above in item 5), BCAA would like the Safety Manager to keep track of the actual safety briefings/lessons/safety promotions performed within the ATO, in from 2017 onward. 9. Management of Change (TAB 8): Every major change in the ATO, may negatively impact safety of the training activities and operations. A risk analysis of the new aspects introduced in the ATO should be performed by the Safety Manager and/or Safety Meeting of the ATO and documented in SIA, together with the risk mitigating measures (if necessary) taken by the ATO. 10. MOC (TAB 9) - FOR INFO ONLY: Overview of the Complexity of change vs Impact of change (for info/clarification to the user) matrix, as a visual aid to assess changes to the ATO. 11. NCO Checklist for Introductory Flights: The Safety Manager, or his deputy is present during Introductory Flights, can use the checklist provided as a guideline for safe conduct of the promotional events for pilot training. BCAA Procedure Manual SIA Revision original 13

14 3.2. BCAA requirements in the use of SIA: All BCAA approved ATO are requested to organize at least 2 SAFETY MEETINGS PER YEAR. All BCAA approved RF (future DTO)* are requested to organize at least 1 SAFETY MEETING PER YEAR. A reasonable spread should be maintained over the course of the year (3 consecutive meeting in 3 days is useless). Additional Ad hoc meetings should be organized when reality so requires. Examples: Occurrence/accident/incident related to the ATO/DTO that requires urgent action, significant change(s) to the ATO, environmental, international or legislative changes, etc. Additional Safety meetings may/should be assembled at the request of any post holder of the ATO (not just the Accountable Manager, or Safety Manager), but may also be combined with other meetings within the ATO/DTO. SIA can serve both as a planning tool (agenda), as well as a reporting tool (minutes of meeting) for the ATO Safety Meetings. The ATO should keep 1 copy of SIA as a Master working document to keep track of evolution and follow-up of occurrences, and the safety actions decided upon within the ATO. Regular back-ups are recommended to avoid data-loss. Failure to produce any SIA filled in properly within the ATO (when there is no other SMS in use), will not be accepted under any pretense (the sadly, we lost all files yesterday -factor) and will automatically lead to a level 1 finding, requiring immediate corrective action, or immediate suspension of the ATO/DTO training activities. Therefore it is up to the ATO/Safety Manager to assure sufficient electronic back-ups, or printed versions of SIA (BCAA prefers paperless, soft copies, to reduce the eco-footprint). * RF = JAR-FCL Registered Facility, or flight club, providing training for PPL and additional ratings. Under the current status of European Air Crew Regulations, will become DTO (or Declared Training Organization, as replacement for BTO, or Basic Training Organization, as planned by EASA NPA , intended to replace the original non-complex ATO). The applicable European Notice for Proposed Amendment (NPA ) regarding EASA DTO (Declared Training Organizations) is expected to be voted and approved over the course of BCAA wishes to anticipate to this impending administrative simplification of requirements for organizations previously designated BTO (Basic Training Organization) and prior as non-complex ATO. BCAA Procedure Manual SIA Revision original 14

15 CHAPTER 4: Getting started with SIA: Please save the initial empty SIA on your computer (or preferably ATO server, or other virtual environment) and perform regular back-ups of the filled in SIA, to avoid data loss. ATO should keep 1 filled-in copy of SIA as a Master working document per year, but updated regularly, related to the mandatory internal Safety Meetings. Starting as of January 1 st 2017, BCAA requests to adhere to the following reference, to save the Master working document of SIA within the ATO: BE-ATO-XXX_SIA_ xls (xxx is the ATO approval reference) The above date is indicative as the date to close off the first year of working with SIA. ATO are requested to forward the SIA Master Working Document to bcaa-ato@mobilit.fgov.be for audit purposes and drawing statistics, on a national level. This for the purpose only of identifying true safety issues (demonstrated objectively from the SIA from all participating ATO) STEP 1: Annual Risk Assessment: Step 1 in the start-up of an SMS within your ATO, is a Risk Assessment of the actual situation (or projected situation if the organization is starting up) in the case of an existing ATO, or converting JAR-FCL RF/FTO/TRTO. BCAA has summed-up 150+ safety hazards threatening today s civil aviation training. The first step in safety management is a self-assessment via brainstorming by the participants to the first Safety Meeting of the ATO ( Kick off ), of the current/projected situation of risks, via the assessment of the estimated PROBABILITY and SEVERITY of each of the risks. BCAA is aware this first step in SMS is a SUBJECTIVE PROCESS (not 100% accurate image of the actual/existing ATO situation), but the kick-off is unavoidably based on personal feeling and experience, of those active in the ATO. It is a first attempt at rendering the hazards threatening the ATO more objective. The Risk assessment should be reevaluated annually (once per year), based on the occurrence follow-up and will inherently become more objective and quantified over time. Each hazard should be assessed for the ATO individually, but comparing its own situation, on a Belgian/European scale. Example: the airport of Ostend (EBOS) is located next to the North Sea. The terrain is flat and there are hardly any obstacles in the vicinity, so the risk of CFIT (Controlled Flight Into Terrain) is lower, compared to the airfield of Saint- Hubert (EBSH) located in the hills of the Belgian Ardennes and much lower than extreme airports like the altiport of Courchevelle (LFLJ) BCAA Procedure Manual SIA Revision original 15

16 4.2. STEP 2: Follow-up of occurrences: The Safety Manager of the ATO should keep track of all the Safety Occurrences reported within the ATO, in TAB 3, Occurrence Follow-up sheet 2017 (FYI: The first major analysis of the effectiveness and overhaul of SIA is planned for end 2017, SIA version 2.0 can be expected and will be forwarded for implementation by all BCAA ATO, as of January 1 st, This may also lead to an online platform, but is not yet guaranteed at this stage). Per reported occurrence, the ATO Safety Manager (or his/her deputy) should: 1. Register a newly reported occurrence in a new TAB 3 of SIA, and summarize the relevant details of the occurrence 2. Perform an RISK IDENTIFICATION of the occurrence (drop down menu in column H of TAB 3), based on the list of European occurrences (the overview can be found in TAB 2) 3. Perform a RISK CLASSIFICATION of the occurrence (Insignificant -> Major), (the overview can be found in TAB 5). 4. Indicate the MAIN CAUSE of the OCCURRENCE 5. Select 1 (or more, with a maximum of 2) CONTRIBUTORY FACTORS 6. Perform a ROOT CAUSE ANALYSIS of the occurrence: 7. Perform an assessment if the occurrence needs FOLLOW-UP (if NO, the occurrence may be closed, if YES the occurrence must be debated during the Safety Meeting). 8. Perform an assessment if the occurrence should be reported to the authorities, in accordance with the items listed in EU 1018/2015, Mandatory Occurrence Reporting STEP 3: Safety Meeting: The Safety Manager (or Accountable Manager) of the ATO should organize at least the minimal amount of required annual Safety meetings (ATO: 2, BTO: 1) in a timely fashion and well in advance, so all persons required can attend. The agenda of a planned Safety meeting, is SIA TAB 3 with an overview of all the safety occurrences in the ATO, of the recent past and the preliminary analysis of the occurrences, performed by the Safety Manager. The Safety meeting should perform an overview of all the Safety occurrences the Safety Manager of the ATO indicated as requiring further follow-up (but the other occurrences may be addressed equally, should any member of the Safety Meeting disagree with the initial assessment of the Safety Manager). It should decide as a group on the course of action to prevent the occurrence from happening again and set up a set of actions and allocate resources. Proposals made by the Safety Manager that are rejected, should be motivated. A responsible Post Holder in the ATO must be allocated for the actions agreed to by the Safety Meeting, in order to avoid reoccurrence and elimination of safety hazards in the future. BCAA Procedure Manual SIA Revision original 16

17 4.4. STEP 4: Follow-up: The effectiveness of previous corrective actions and precautionary measures taken to prevent reoccurrence, should be reevaluated (if possible) by the Safety meetings and a rerun of the risk assessment should be performed. If reoccurrence is estimated sufficiently mitigated, the occurrence may be closed. Occurrences that were not closed during a previous Safety meeting and that are still not closed after re-evaluation, or cannot be closed by a consecutive Safety meeting, should be marked in blue ( Long term solution ), and may be closed. This can be the case if the ATO has no direct influence on the hazard, due to for example environmental, or legislative issues, or when a significant investment of time and resources is required over a larger period of time. This however requires proper motivation by the ATO Safety Manager, or Safety meeting. SIA also serves the purpose as report of the Safety meeting (no other notes, or minutes of meeting is required as proof the meetings were organized) STEP 5: Safety planning: The results generated by SIA for a particular ATO after one calendar year, should result in a Safety plan for the next year (the results of SIA of 2016, should result in the Safety plan of 2017). The Safety Manager, or the Safety meeting should distill out of the results kept in SIA TAB 7 listing 5 MAIN HAZARDS, 5 TYPES OF OCCURRENCES AND 5 MAIN CAUSES OF OCCURRENCES, the ATO wishes to address during in the following year. The Safety Manager, or meeting, may select from a number of safety actions to focus on, during the next calendar year STEP 6: Safety briefing & promotion: The Safety briefings performed in the light of the focal points, identified in STEP 5, may be kept track of in the next tab (TAB 8 Safety briefings & promotion): The Safety Manager should keep track of all the briefings and promo that was performed (by him/herself, instructors, post holders, or other persons active in the ATO), to demonstrate there is a positive/continuous tendency towards and focus on aviation safety within the ATO STEP 7: Management of Change: A fully developed, mature ATO manages its own internal processes of compliance with the applicable legislation and maintaining the highest standards of safety. One of the more recent principles of running a safe operation is Management of Change : if there is a major change implemented within the ATO, the Safety Manager should be asked to perform a risk analysis on the extra hazards posed by the changes to the organization. BCAA Procedure Manual SIA Revision original 17

18 This constitutes the following: 1. Description of the change 2. Listing the risks the changes proposed to the organization will/might generate 3. Performing a risk analysis on each of the identified risks 4. Mitigation of the risks identified 5. Execution of the change 6. Action plan and follow-up of the actions taken 7. Reassessment of the remnant risk, after risk assessment and implementation of the remedial, risk mitigating actions 8. Final corrective actions 9. Closure of the change to the ATO, if successful, or return to the previous situation (before the change was implemented), if the change to the ATO was estimated unsuccessful, uneconomic, unsafe, not overall beneficiary, or other STEP 8: Use of SIA/SMS as a Management tool: An ATO with a well-developed SMS and Safety culture, will use the results produced by SIA as a Management tool, for the benefit of the ATO. An annual presentation to all those involved in the ATO (leaflet, presentation, or other) is indicative of the maturity and overall acceptance of SMS as a benefit for the ATO. Essential data for feedback is automatically generated by SIA, in TAB 6, VISUAL REPRESENTATION. Feedback to all participants of the ATO s SMS (all who is reporting occurrences) is key to continuing a Reporting culture within the ATO. It is strongly recommended that all involved in the ATO, would receive feedback at least once a year (general, not addressed to individuals, or per sé occurrencespecific) on the reported occurrences within the ATO (or other interesting cases outside the ATO) and the outcome and initiatives and measures taken by the ATO to avoid reoccurrence. BCAA Procedure Manual SIA Revision original 18

19 CHAPTER 5: Feedback of SIA to BCAA: All feedback regarding SIA for improvement and optimization may be forwarded to It is requested that all users under BCAA supervision, would forward the filled out (not disclosing any names of pilots/instructors/flight club members would be disclosed) SIA in the above mentioned extension after 31/12/2017, for the purpose of auditing the ATO SMS and generating statistics for the Belgian airspace. BCAA Procedure Manual SIA Revision original 19