TANZANIA CIVIL AVIATION AUTHORITY AERODROMES AND AIR NAVIGATION SERVICES. Foreword

Transcription

1 AERODROMES AND AIR NAVIGATION SERVICES Revision: 1 Title: ANS Inspector Handbook Page 1 of 62 Foreword The Civil Aviation safety oversight program has been implemented to promote and ensure conformance with the Civil Aviation Regulations and Standards, collectively prescribing an acceptable level of aviation safety within Tanzania In conducting regulatory inspections and Inspection/audits, and documenting the activity process, the Authority is able to assess and determine the level of conformance to regulatory requirements for the Air Navigation Service Providers within the country. This manual outlines the directions, processes and procedures for conducting Inspection/audits of Air Navigation Services and facilities. Adherence to the guidance herein is imperative and will ensure Inspection/audit policies and procedures are uniformly applied across Tanzania. To maintain overall effectiveness of the Inspection/audit activity, our approach to each organization must be one of transparency, with a high degree of professionalism, using experience, skills and communication as essential ingredients. The aviation community must view our program as one that is fair and equitable in its application. Tanzania Civil Aviation Authority 20 March 2013

2 AERODROMES AND AIR NAVIGATION SERVICES Revision: 1 Title: ANS Inspector Handbook Page 2 of 62 Record of Amendments Amendment Number Amendment Date Date Entered Entered by 20 March 2013

3 AERODROMES AND AIR NAVIGATION SERVICES Revision: 1 Title: ANS Inspector Handbook Page 3 of 62 DISTRIBUTION LIST Serial No. Issued to Date March 2013

4 AERODROMES AND AIR NAVIGATION SERVICES Revision: 1 Title: ANS Inspector Handbook Page 4 of 62 LIST OF EFFECTIVE PAGES Page Date Page Date Page Date 1 22 Jan Jan 2010 APP Jan Jan Jan 2010 APP Jan Jan Jan 2010 APP Jan Jan 2010 Chapter 6 APP Jan Jan APP Jan Jan Jan 2010 APP Jan Jan Jan 2010 APP Jan Jan Jan 2010 APP Jan Jan Jan 2010 APP Jan 2010 Chapter Jan 2010 APP Jan Jan Jan 2010 APP Jan Jan 2010 Chapter 7 APP Jan Jan Jan 2010 APP Jan Jan 2010 Chapter 8 APP Jan 2010 Chapter Jan 2010 APP Jan Jan 2010 APP Jan Jan 2010 APPENDICES APP Jan Jan 2010 APP Jan 2010 APP Jan Jan 2010 APP Jan 2010 APP Jan Jan 2010 APP Jan 2010 APP Jan Jan 2010 APP Jan 2010 APP Jan Jan 2010 APP Jan 2010 APP Jan 2010 Chapter 3 APP Jan Jan 2010 APP Jan 2010 FORMS Jan 2010 APP Jan 2010 FM Jan Jan 2010 APP Jan 2010 FM Jan Jan 2010 APP Jan 2010 FM 2 22 Jan Jan 2010 APP Jan 2010 FM 3 22 Jan Jan 2010 APP Jan Jan 2010 APP Jan 2010 FM 5 22 Jan Jan 2010 APP Jan 2010 FM 6 22 Jan Jan 2010 APP Jan Jan 2010 APP Jan 2010 FM 8 22 Jan Jan 2010 APP Jan 2010 FM 9 22 Jan Jan 2010 APP Jan 2010 FM Jan March 2013

5 AERODROMES AND AIR NAVIGATION SERVICES Revision: 1 Title: ANS Inspector Handbook Page 5 of Jan 2010 APP Jan 2010 FM Jan Jan 2010 APP Jan 2010 FM Jan 2010 Chapter 4 APP Jan 2010 FM Jan Jan 2010 APP Jan 2010 FM Jan Jan 2010 APP Jan 2010 Chapter 5 APP Jan Jan 2010 APP Jan March 2013

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7 Title: ANS inspectors Handbook Manual Page 7 of 62 TABLE OF CONTENTS Forward...1 Record of Amendments Distribution List List of Effective Pages CHAPTER GENERAL Definitions Abbreviations Objectives of the Manual Applicability Authority for publication and amendment of the manual CHAPTER GENERAL POLICY AND PROCEDURE Introduction Director General, Civil Aviation ANS Inspectors Handbook CAA Safety Inspection/audit Program Safety Oversight Directorate Authority Director General, Civil Aviation Inspector delegation of authority Inspection/Audit plan Inspection/Audit types General Pre-certification Inspection/Audit Additional authority Inspection/Audit Routine conformance Inspection/Audit Special-purpose Inspection/Audit Scope and depth Frequency Inspection/Audit budget Inspection/Audit phases General Pre-Inspection/Audit Physical Inspection/Audit... 19

8 Title: ANS inspectors Handbook Manual Page 8 of Post-Inspection/Audit Inspection/Audit follow-up Checklists Purpose Applicability Safety management system assessment guide Inspection/Audit team Inspection/Audit assignments Inspector/Auditor qualification Inspection/Audit coordination Specialist Observers Director of Safety Regulation role Parallel findings and observations Discrepancies within CAA mandate Confidentiality Inspection/audit report Inspection/audit record retention and disposal CHAPTER INSPECTION/AUDIT PROCEDURES Selection of inspection/audit Procedures Pre-inspection/audit Notification Inspection/Audit Team Requirements Inspection/Audit Plan Pre-inspection/Audit File and Documentation Review Inspection/Audit File Pre-Inspection/Audit Team Meeting Physical Inspection/Audit General Entry Meeting Evaluation and Verification Inspection/Audit Findings Daily briefings Exit Meeting Post-Inspection/Audit process Inspection/Audit report General Report format... 32

9 Title: ANS inspectors Handbook Manual Page 9 of Report procedures Inspection/Audit follow-up General Types of corrective action Corrective action plan submission Corrective action acceptance Corrective action follow-up Aviation enforcement action Inspection/Audit report review committee Post-Inspection/Audit surveillance PARALLEL FINDINGS AND OBSERVATIONS General Parallel findings Parallel findings shall include; Follow-up Parallel observation Follow-up action INSPECTION/AUDIT TEAM QUALIFICATIONS AND RESPONSIBILITIES Team selection The Director of Safety Regulation Responsibilities Team Leader Terms of reference Qualifications Responsibilities Team Member Terms of reference Qualifications Responsibilities CHAPTER INSPECTOR TRAINING, QUALIFICATIONS AND CREDENTIALS Introduction Types of training Initial training Specialized training Recurrent training Training for re-qualification On-job-training (OJT) Training plan... 49

10 Title: ANS inspectors Handbook Manual Page 10 of Training records Inspector Qualifications Credentials CHAPTER ANS INSPECTION FIELDS AND PROCEDURES General Inspection fields APPENDICES Appendix 1 Aerodrome Inspection Checklist APP 1-1 Appendix 2 Aerodrome and Approach Combined Checklist.APP 2-1 Appendix 3 Approach Inspection Checklist.APP 3-1 Appendix 4 Area Control Inspection Checklist APP 4-1 Appendix 5 AIS Aerodrome Unit Inspection Checklist APP 5-1 Appendix 6 AIS NOF Inspection Checklist.APP 6-1 Appendix 7 AIS Cartographic Unit Inspection Checklist APP 7-1 Appendix 8 AIS Headquarters Inspection Checklist APP 8-1 Appendix 9 CNS Inspection Checklist.APP 9-1 Appendix 10 Meteorology Inspection Checklist APP 10-1 Appendix 11 - Procedure Design APP 11-1 Appendix 12 Search and Rescue Inspection Checklist APP 12-1 FORMS FM 1 - ANSP Application/Renewal/Amendment Form FM 2 - Air Navigation Services Provider Register FM 3 - Confirmation Request Form FM 4 - Confirmation Request Tracking Form FM 5 - Corrective Action Form FM 6 - Corrective Action Form Part 1 FM 7 - Corrective Action Form Part 2 FM 8 - Corrective Action Tracking Form FM 9 - Evidence Log FM 10 - Finding Form FM 11 - Parallel Finding Form FM 12 Parallel Observation Form FM 13 - Navigation Service Provider Certificate

11 1.1. Definitions Title: ANS inspectors Handbook Manual Page 11 of CHAPTER GENERAL 3. The following terminology is specific to this manual and to those portions of associated manuals that pertain to inspections and Inspection/audits: Audit: An in-depth review of the activities of an organization to verify conformance to regulatory requirements; Audit activities: Those activities and procedures through which information is obtained to verify conformance to regulatory requirements; Auditee: The organization to be audited. This term may be interchanged with company, document holder, operator and organization ; Audit finding: A non-conformance to a specified regulatory requirement or company approved procedure, identified during an audit and documented on a finding form; Audit report: A report that outlines the audit process and provides a summary of the audit findings; Certification: The process of determining competence, qualification, or quality on which the issuance of a [State] aviation document is based. This includes the original issuance, denial, renewal or revision of that document; Confirmation: The assurance that findings are in accordance with data obtained from different sources; Confirmation request form (CRF): A form issued to an organization by an inspector requesting specific information. The organization is requested to respond within a specified period; Conformance: The state of meeting regulatory requirements or organization s approved procedures;

12 Title: ANS inspectors Handbook Manual Page 12 of 62 Corrective action plan: A plan submitted in response to findings. The plan outlines how the company proposes to correct the deficiencies documented in the findings; Documented: That which has been recorded in writing, photocopied or photographed and then signed, dated and retained; Finding: A non-conformance to a regulatory requirement or company approved procedure; Finding form: A form used to document a finding; Follow-up: The final audit phase that focuses on corrective action to findings issued during an audit; Inspection: The basic activity of an audit, involving the systematic assessment of a specific characteristic of an organization to verify conformance to regulatory requirements or company approved procedures. The term also refers to inspector tasks exercised in the performance of this activity; ANS Inspectors' Handbook: A manual outlining general audit policies and procedures and serving as the principal guidance document for the conduct of inspection/audits within [CAA]; Inspection field: The area or unit within the ANSP to be inspected/audited; Non-conformance: The failure to meet regulatory requirements or company approved procedures; Practice: The method by which a procedure is carried out; Procedure or process: A series of steps followed methodically to complete an activity. This includes: the activity to be done and individual(s) involved; the time, place and manner of completion; the materials, equipment, and documentation to be used; and the manner in which the activity is to be controlled; Quality assurance activities (QAA): A series of planned activities to determine whether the management system conforms to the requirements of the operating

13 Title: ANS inspectors Handbook Manual Page 13 of 62 standards. These activities include quality assurance reviews and selfassessments; Standard: An established criterion used as a basis for measuring an organization s level of conformance; Team leader: The individual appointed under the authority of the [Director of Safety oversight] to lead an audit team. Team member: The individual appointed under the authority of the [Director of Safety oversight] to participate in safety audit; Working papers: All documents required by the auditor or audit team to plan and implement the audit. These may include inspection schedules, assignments, checklists and various report forms Abbreviations The following abbreviations and acronyms will be found throughout this manual and in functional area control manuals, including checklists and other guidance materials: ANS Air Navigation Services ANSP Air Navigation Services Provider ATC Air Traffic Control ATM Air Traffic Management CAA Civil Aviation Authority CARs Civil Aviation Regulations CNS Communication, Navigation and Surveillance DG Director General HQ Headquarters ICAO International Civil Aviation Organization IFR Instrument Flight Rules MANSOPS Manual of Air Navigation Services Operations N/A Not Applicable NOTAM Notice to Airmen QA Quality Assurance QAA Quality Assurance Activities QC Quality Control SAR Search and Rescue

14 Title: ANS inspectors Handbook Manual Page 14 of 62 SMS Safety Management System

15 Title: ANS inspectors Handbook Manual Page 15 of Objectives of the Manual (a) To provide guidance to ANS Inspectors administering the inspection and inspection/audit programme. (b) To promote standardization in application of programme procedures and practices. (c) To fulfill the ANS certification requirements in accordance with the Civil Aviation Regulations. (d) To encourage and promote the establishment of reasonable programmes for enhancing and improving safety to benefit the aviation community Applicability The categories of Air Navigation Service Providers Inspected/audited under the provisions of this manual are; Air Traffic Services, Meteorological Services for air navigation, Aeronautical Information Services, Search and Rescue, Communication, Navigation and Surveillance Systems and Flight procedure design Authority for publication and amendment of the manual The ANS Inspectors Handbook is developed, published and distributed pursuant to Civil Aviation (ANS) Regulations, The Authority is responsible for the issuance and control of amendments to this manual. All copies of the manual are numbered and issued in accordance with the distribution list. Individual holders are responsible for insertion of all amendments. Minor changes (e.g. telephone number, typographical errors) can be accommodated by hand amendment with prior notification to the Authority. All such changes will be incorporated accordingly All users of this manual are encouraged to submit recommendations for proposed revisions, additions or omissions to the Authority for consideration and inclusion in the amendments as appropriate.

16 Title: ANS inspectors Handbook Manual Page 16 of 62 CHAPTER 2 GENERAL POLICY AND PROCEDURE 2.1 Introduction Director General, Civil Aviation The [Director General], Civil Aviation is responsible for the development of inspection and audit policy and procedures contained in this handbook ANS Inspectors Handbook This handbook outlines general inspection/audit policy and procedures and serves as the principal guidance document for the conduct of inspection/audits and includes checklists, forms and guidance materials that will be used by Inspectors in the course of their inspection and audit activities CAA Safety Inspection/audit Program The CAA Safety inspection/audit Program has been developed to promote conformance with the Civil Aviation Regulations and associated standards Safety Oversight Directorate The Director of Safety Regulation is responsible for the management of the Safety Oversight inspection/audit Program, which includes the following: (a) defining inspection/audit policy, procedures and training standards; (b) managing inspectors training program(s); (c) maintaining the safety oversight and inspection/audit manual and assisting in the development and management of documents required for the inspection/audit process; (d) administering the safety oversight inspection/audit program to ensure uniform application of Civil Aviation inspection/audit policies and procedures; and (e) coordinating inspection/audit activities. 2.2 Authority

17 Title: ANS inspectors Handbook Manual Page 17 of Director General, Civil Aviation The Director General, Civil Aviation (DGCA) is responsible for the development of inspection and audit policy and procedures. The appropriate responsibilities have been delegated to Director responsible for safety regulations pursuant to section 20 of the Civil Aviation Act CAP 80 as reflected in the Delegation of Powers by the Director General. Pursuant to the above powers the DGCA has provided policy and procedural guidance for the conduct of safety oversight Inspection/Audit through this safety oversight Inspection/Audit manual Inspector delegation of authority The Director responsible for aviation safety oversight shall appoint Inspectors/Auditors to carry out assessment and Inspection/audits who shall have unhindered access to aircraft, aerodrome and related facilities and installations, navigation and communication facilities and to any records and information. The Civil Aviation Act provides for Inspectors/Auditors to take appropriate action to ensure that safety deficiencies are corrected and appropriate standards are maintained. 2.3 Inspection/Audit plan The inspections/audits of organizations shall be done in accordance with a plan prepared by the Director of Safety Regulation as contained in Chapter 3 of this handbook. 2.4 Inspection/Audit types General The type of inspection/audit is determined by the circumstances under which the inspection/audit is convened and includes the following: (a) pre-certification inspection/audit; (b) additional authority inspection/audit; (c) routine conformance inspection/audit; and (d) Special-purpose inspection/audit Pre-certification Inspection/Audit

18 Title: ANS inspectors Handbook Manual Page 18 of 62 Pre-certification inspection/audit will be conducted prior to the issuance of the certificate Additional authority Inspection/Audit An additional authority inspection/audit may be conducted prior to the granting of an additional authority. Prior notification to the organization is not required Routine conformance Inspection/Audit A routine conformance inspection/audit will be conducted for the purpose of determining an organization s overall level of conformance to regulatory requirements. All applicable characteristics of the organization will be subject to review Special-purpose Inspection/Audit A special-purpose inspection/audit is one conducted to respond to safety concerns or circumstances other than those requiring a pre-certification Inspection/audit, an additional authority inspection/audit or a routine conformance inspection/audit. A special purpose inspection/audit may preclude certain teammember activities and responsibilities that would be associated with other types of Inspection/audits. 2.5 Scope and depth The scope and depth of an inspection/audit is influenced by the following: (a) type of the inspection/audit; (b) the period back in time that systems are subject to review (typically from the last inspection/audit to the present); (c) the enforcement record of the organization; (d) the confidence in corrective actions taken by the organization as a result of a previous inspection/audit; and (e) Inspector/Auditor and financial resources available 2.6 Frequency With the exception of pre-certification, additional authority and special purpose inspection/audits, organizations shall be inspected/audited at least once a year.

19 Title: ANS inspectors Handbook Manual Page 19 of Inspection/Audit budget The Director of Safety Regulation is responsible for resource utilization and control during inspection/audits. Where applicable, forecast expenditures will be included in the proposed Inspection/audit plan and should include a breakdown of travel and overtime costs for all Inspection/audit activities. Once the budget has been approved, the Director of Safety Regulation will ensure that expenditures fall within approved allocation. 2.8 Inspection/Audit phases General The Inspection/audit process consists of the following four distinct phases: (a) pre-inspection/audit; (b) physical inspection/audit; (c) post-inspection/audit; and (d) Inspection/audit follow-up Pre-Inspection/Audit Pre-inspection/audit activities involve notifying the organization, selecting an inspection/audit team, developing an inspection/audit plan, reviewing files and related documentation, opening an inspection/audit file if one has not been opened prior to the inspection/audit, and convening the pre-inspection/audit team meeting. Further details are given in section 3.2 of this manual Physical Inspection/Audit The physical inspection/audit phase will be implemented in accordance with the inspection/audit plan. The purpose of this phase is to verify conformance with regulatory requirements and to assign findings where non-conformance has been confirmed. Inspection/audit results will be communicated to the organization under review at daily meetings and/or the exit meeting. Once an inspection/audit has commenced, it will not be terminated without approval of the Director of Safety Regulation. Further details on Physical Inspection/audit are given in section 3.3 of this manual.

20 Title: ANS inspectors Handbook Manual Page 20 of Post-Inspection/Audit Post-inspection/audit activities include completion of administrative details and production of the inspection/audit report. Details of post Inspection/audit activities are given in section 3.4 of this manual Inspection/Audit follow-up Inspection/audit follow-up includes acceptance of the organization s corrective action plan, verification of full implementation of that plan and formal closure of the Inspection/audit by the team leader. Further details on inspection/audit followup are given in section 3.5 of this manual. 2.9 Checklists Purpose Checklists provide a systematic approach for the conduct of an inspection/audit and are designed to identify specific items for review and make reference to the applicable regulatory requirement, be it to a regulation, standard or control manual requirement. Checklists should not limit the inspector/auditor s ability to explore other areas where warranted Applicability Inspection/audit checklists will: (a) be used to guide the inspection/audit; (b) be completed or have areas that were not completed so annotated; and (c) be signed and dated by the team member using the checklist Safety management system assessment guide Where an assessment of an organization s safety management system (SMS) will be completed, the SMS assessment guide shall be used Inspection/Audit team

21 Title: ANS inspectors Handbook Manual Page 21 of Inspection/Audit assignments Inspectors/ Auditor assigned to an inspection/audit team shall report to the team leader for the duration of the inspection/audit. To ensure continuity, Inspectors/Auditor assigned to an inspection/audit shall not be released from their duties prior to the completion of their assignments set out in the inspection/audit plan unless written authorization has been received from the Director of Safety Regulation. Team members must be able to focus on inspection/audit activities and must therefore be released from other responsibilities during the term of the Inspection/audit Inspector/Auditor qualification Inspection/audit team member qualifications will vary according to their respective duties and responsibilities and are specified in Chapter 4 of this manual. Where the qualifications referred to above have not been met, persons providing specialist assistance and Inspector/Auditor under training may be included as team members with the approval of the Director of Safety Regulation. Any work undertaken by these individuals must be reviewed by a qualified member who will sign and take responsibility for work completed Inspection/Audit coordination Inspection/audits will be coordinated through the Director of Safety Regulation Specialist A specialist may join the inspection/audit team by mutual agreement of the Director of Safety Regulation and appropriate team leader Observers An observer may join the Inspection/audit team by mutual agreement of the Director of Safety Regulation, appropriate team leader and the ANSP. This observer may be a CAA Inspector/Auditor or any other person authorized by the Director of Safety Regulation.

22 Title: ANS inspectors Handbook Manual Page 22 of Director of Safety Regulation role The Director of Safety Regulation shall monitor the effectiveness of inspection/audit plans by using policies and procedures outlined in this manual Parallel findings and observations When parallel findings or observations are identified during an inspection/audit, the required form will be completed in accordance with sections and and follow-up is to be conducted in accordance with section and Discrepancies within CAA mandate During an inspection/audit, the organization under review may produce CAA letters or approval documents that are inconsistent with current regulation or policy. Where non-conformance to a regulatory requirement results, an inspection/audit finding will be assigned to the organisation under review to ensure that it is resolved through the corrective action plan. The inspector shall include these inconsistencies in a parallel finding Confidentiality Owing to the sensitive nature of inspection/audits, confidentiality of inspection/audit information is important; this is especially true during the physical inspection/audit. Inspector/Auditor shall exercise judgment and discretion when discussing matters pertaining to the inspection/audit whether on or off the site. Discussion of inspection/audit content shall be limited to the inspection/audit team and CAA management and shall be undertaken in accordance with the communication protocols specified in the Inspection/audit plan Inspection/audit report The inspection/audit report is the documentary result of an inspection/audit and is required for each inspection/audit. The report outlines the inspection/audit process, provides a summary of the areas under review and includes copies of any inspection/audit findings. Section outlines the general procedures for preparing an inspection/audit report.

23 Title: ANS inspectors Handbook Manual Page 23 of Access to information Any request for inspection/audit records must be processed upon receipt by the authority In the case of ongoing inspection/audits where disclosure of the requested inspection/audit documents will be injurious to the decision making process (and/or the deliberations between Director of Safety Regulation and the approved organization) Director of Safety Regulation shall make recommendations for nondisclosure of the relevant portions of requested records Inspection/audit record retention and disposal The process for disposal and/or retention of inspection/audit records will be determined by the requirements of the National Archives of Tanzania in conjunction with the Disposal Act and any CAA disposal policy that may be in place.

24 Title: ANS inspectors Handbook Manual Page 24 of 62 CHAPTER 3 INSPECTION/AUDIT PROCEDURES 3.1 Selection of inspection/audit Procedures Inspection/audit procedures are similar in application yet there are differences attributable to the size, scope and complexity of the organizations being inspected/audited. With some types of inspections/audits, not all procedures outlined in this Chapter will be employed. 3.2 Pre-inspection/audit The phases of the pre-inspection/audit involve, among other things, notifying the organization, selecting an inspection/audit team, developing an inspection/audit plan, reviewing files and related documentation, opening an inspection/audit file if one has not been opened prior to the inspection/audit, and convening the preinspection/audit team meeting Notification An organization will normally be contacted at least fourteen (14) days prior to the planned inspection/audit date to confirm the inspection/audit schedule. The notification period for inspections/audits planned on shorter notice will be at the discretion of the Authority. The scope of the Inspection/audit will determine the lead-time for this contact Inspection/Audit Team Requirements Inspection/audit team requirements including team member selection, terms of reference, qualifications and responsibilities are specified in Chapter 5 of this Manual Inspection/Audit Plan The Director of Safety Regulation will develop an inspection/audit plan. This plan ensures that the inspection/audit will be conducted in an organized manner and in accordance with predetermined criteria. Appropriate sections of the plan will be distributed to each member of the inspection/audit team to provide guidance and

25 Title: ANS inspectors Handbook Manual Page 25 of 62 direction throughout the inspection/audit. The inspection/audit plan should address the following items as applicable: a) Objective The inspection/audit plan should state the inspection/audit type (section 2.5) as applicable (i.e., Pre-certification, Routine Conformance inspection/audit, Additional authority or Special Purpose inspection/audit). b) Scope and Depth The following should be specified where applicable: (i) the specialty areas (including elements therein) of the organization to be inspected/audited; (ii) the duration of the inspection/audit; c) Organization Description The inspection/audit plan should provide specific information on the organization. This will provide the Inspector/Auditor with an overview of the organization and will include information pertaining to the following: (i) the number of employees and their location; (ii) type of operation; and (iii) any other relevant information d) Methodology The inspection/audit plan should describe the methodology to be used during the inspection/audit including: (i) the manner in which the Inspection/audit is to be conducted (i.e., procedures specified in this manual). (ii) the specific procedures to be followed (specialist guidance such as checklists, forms and guidance materials provided in this manual); and (iii)details pertaining to maintenance of the inspection/audit file required by section e) Communications The inspection/audit plan should identify the communication protocols that the inspection/audit team is to follow. This will include internal communications within the inspection/audit team and CAA personnel, as well as external communications with the ANSP, external agencies and the public. f) Specialist Assistance Specialists are persons who possess knowledge and expertise that is required of the inspection/audit team yet is not available within the Authority.

26 Title: ANS inspectors Handbook Manual Page 26 of 62 g) Parallel Findings and Observations The inspection/audit plan will indicate the process team members will follow when parallel findings or observations are identified. h) Budget The inspection/audit plan shall include the budget for the expenses to be incurred during the implementation of the programme. i) Team Composition The inspection/audit plan shall include a list of the inspection/audit team members, technical specialties and telephone number. j) Inspection/audit Schedule An inspection/audit schedule shall be provided indicating the pre-inspection/audit and physical inspection/audit activities including dates and time Pre-inspection/Audit File and Documentation Review This includes a thorough review of all files and documentation that are relevant to the organization. The following should be completed during this activity where applicable: (a) ensure that all reference manuals and documents to be used during the inspection/audit are readily available and include the latest approved amendments; (b) review the ANSP s approved manuals for conformance to the appropriate standard; (c) review the ANSP s files and records to include: (i) previous inspection/audits including corrective actions and follow-up where applicable, (ii) accident or incident data, including incident reports, (iii) previous enforcement action, and (iv) exemptions, waivers, approvals, limitations and authorizations; (d) identify areas that require further review during the physical inspection/audit; (this can be added to the notes section of the applicable checklist.) (e) Select the applicable checklist(s) from this manual in accordance with the scope of the inspection/audit; and (f) complete all applicable pre-inspection/audit items on the checklists

27 Title: ANS inspectors Handbook Manual Page 27 of Inspection/Audit File An inspection/audit file is required to track inspection/audit history and help determine inspection/audit frequency. It is also valuable in assessing the effectiveness of inspection/audit follow-up. An inspection/audit file shall be opened for each organization that is inspected/audited. The inspection/audit file shall contain a complete chronological record of all correspondence(s) and documentation dealing with inspections/audits including a complete record of inspection/audit follow-up action. Items that appear inconsistent or incomplete during a review of the inspection/audit file must be distinctly marked for verification during the physical inspection/audit Pre-Inspection/Audit Team Meeting This meeting should include the following agenda items as applicable for the type of inspection/audit: (a) administrative details; (b) inspection/audit plan review and amendment, ensuring that all team members have received appropriate inspection/audit plan; (c) confidentiality and access to information; (d) use of checklists; (e) communications; (f) pre-inspection/audit review and physical inspection/audit overview; and (g) where possible, Inspector/Auditor briefing on the organization s current activities, trends, performance and previous inspection/audit history including corrective action and follow-up. 3.3 Physical Inspection/Audit General Activities conducted during the physical inspection/audit include the entry meeting, evaluation and verification, daily briefings and the exit meeting Entry Meeting

28 Title: ANS inspectors Handbook Manual Page 28 of 62 The entry meeting should set the tone for the physical inspection/audit and should be attended by the ANSP s senior management. Members of the inspection/audit team will attend the entry meeting as directed by the Director of Safety Regulation. Additional personnel may attend as directed by the Director of Safety Regulation. This meeting will outline the inspection/audit process and confirm any administrative requirements so that the physical inspection/audit may be conducted both effectively and efficiently, while minimizing disruptions to the ANSP operations Evaluation and Verification Use of Inspection/Audit Checklists Use of the applicable checklists contained in this manual is mandatory, as they will assist Inspectors in determining the level of conformance to regulatory requirements. Based on the results of the completed checklist, a determination of the strengths and weaknesses of the ANSP s control system will be possible. Although each item on the checklist need not be checked, this system will be most effective if all items are evaluated. There may be times where it is not possible to review a particular specialty area element (i.e., an entire checklist). This shall be documented in the Inspection/audit report and where applicable, a parallel observation submitted. During this phase, the inspection/audit team will; (a) confirm whether the ANSP s operation conforms to regulatory requirements; (b) confirm whether controls are operating effectively and as intended and specified in the appropriate manual; and (c) where non-conformance with a regulatory requirement is identified, gather evidence or supporting documentation (with the assistance of the enforcement point-of-contact if required) and prepare an inspection/audit finding Inspections Inspections range from the simple observation of an activity to the detailed analysis of a system or process using comprehensive checklists or forms. The term inspection includes: the review of files and records, interviews, use of confirmation requests, observation of such activities as air traffic control operations.

29 Title: ANS inspectors Handbook Manual Page 29 of Interviewing ANSP Personnel Interviews are verbal communications with the ANSP s personnel and range from an informal discussion to prearranged interviews. Interviews are important to inspectors/ Auditor in that they enable the Inspector/Auditor to: (a) determine whether the control system documented in control manuals is in use; (b) determine the accuracy of information provided; (c) assess the knowledge of supervisory personnel pertaining to their duties and responsibilities; and (d) where applicable, confirm the validity of findings identified during an inspection/audit Guidelines for preparing the interview The following guidelines will be useful when preparing for an interview: (a) prepare carefully prior to the interview by defining the areas to be explored and setting specific objectives (guidance material may be included in the appropriate manual); (b) explain why the interview is taking place; (c) use open ended questions and avoid complex questions or phrases; (d) ensure that questions are understood; (e) listen carefully to answers and allow interviewee to do most of the talking; (f) avoid being side-tracked from your original objectives; (g) terminate the interview if the atmosphere becomes highly negative; (h) thank the interviewee at the conclusion of the interview; and (i) document responses during or as soon as possible following the interview Confirmation Requests Confirmation requests are typically used where the Inspector/Auditor requires information and the appropriate company representative is not immediately available to provide it. Communications are entered on the Confirmation Request Form (CRF) and forwarded to the ANSP with a request that the information be provided by a specified date and time. A sample CRF can be found in Appendix 2 of this manual. Team members will forward CRFs to the team leader who will review the document to ensure that it is recorded in a Confirmation Request Tracking Form (CRTF-Appendix 2) and forwarded to the appropriate person in the ANSP s organization.

30 Title: ANS inspectors Handbook Manual Page 30 of 62 When the CRF has been returned and appropriate action taken, this material should be filed Inspection/Audit Findings General Inspection/audit findings must be prepared accurately as they form the basis of the inspection/audit report and a successful inspection/audit. A sample finding form can be found in Appendix 2. Since a number of team members will be completing finding forms, it is important that a standardized approach to inputting data on the form be taken. All evidence and supporting documentation will be included with the completed finding form for review by the applicable team leader and the Director of Safety oversight. Although this documentation will not be included in the inspection/audit report, it will be retained in the inspection/audit file Issuance during the Physical Inspection/Audit Where it is determined that corrective action and subsequent follow-up to a non-conformance is required in a period less than that which occurs through the use of an approved corrective action plan (typically 30 working days), an inspection/audit finding may be issued during the physical inspection/audit. This type of finding is usually made where safety is compromised and corrective action is required immediately, or at the very least, prior to completion of the inspection/audit. The corrective action section of the inspection/audit finding form includes a checkbox and a line to specify the date and time by which that corrective action is required. The ANSP must respond to the inspection/audit finding by the date and time specified in the corrective action section of the finding form using a corrective action form. A sample corrective action form can be found in Appendix 2. Issuance of inspection/audit findings during the physical inspection/audit will only be contemplated when the Director of Safety oversight and team leader are in agreement with such action. For the purposes of follow-up to corrective actions taken during the physical inspection/audit, the team leader or Director of Safety oversight will accept submitted corrective actions by signing the applicable corrective action form.

31 Title: ANS inspectors Handbook Manual Page 31 of Filling the finding form The finding form must be dully completed by the Inspector /Auditor, while observing the following; a) identify the ANSP using the organization s name as found on the register and file number, b) identify the area of inspection/audit c) enter the location where the non-conformance applies, d) for each non-conformance, correctly identify the regulatory requirement or company approved procedure to which it applies and quote the regulatory requirement or company approved procedure word for word, ensuring that the quotation is relevant or insert the reference in approved manuals e) ensure that the examples illustrate non-conformance with the applicable requirement be it a regulation or a standard f) avoid the use of unnecessary words g) specify the name of the Inspector/Auditor and the date the inspection/audit finding was made Daily briefings Team briefings should be held at the end of each day during the inspection/audit to; a) ensure adherence to the inspection/audit plan; b) validate confirmation requests and inspection/audit findings; c) resolve issues or problems arising from the day s activities; and d) provide the team leader with the information necessary to update the Authority where applicable. Daily briefings for the ANSP should be scheduled to minimize any disruption. These briefings are conducted to update the ANSP s management on inspection/audit progress and to discuss any identified findings Exit Meeting Upon completion of the inspection/audit, the team leader will convene an exit meeting with the ANSP s senior management to brief them on the results of the inspection/audit. Where applicable, the inspection/audit team will have briefed the ANSP on all inspection/audit findings during the daily meetings so debate between the team

32 Title: ANS inspectors Handbook Manual Page 32 of 62 and the organization should not occur. The ANSP should be advised that they will have an opportunity to respond formally to the inspection/audit report in their corrective action plan submission. The team leader shall advise the ANSP that the inspection/audit report will be forwarded to them within 10 working days from the completion of the exit meeting and that a corrective action plan must be submitted within 30 days after the report has been received. Details of the corrective action process will also be discussed. 3.4 Post-Inspection/Audit process The post-inspection/audit process includes the wrap-up of inspection/audit administrative details (claims, overtime, etc.), preparing the inspection/audit report and convening the inspection/audit report review committee where applicable. 3.5 Inspection/Audit report General The inspection/audit report is a document that summarizes the results of an inspection/audit and includes the inspection/audit findings and where applicable, corrective actions taken to findings issued during the inspection/audit in accordance with section The report is a factual account of the inspection/audit and will not include subjective statements, suggestions or recommendations. The team leader is responsible for the preparation of the inspection/audit report and its submission for approval Report format The inspection/audit report will have three distinct parts as follows: a) Part I Introduction, which identifies the ANSP, summarizes the inspection/audit process and includes the executive summary which summarizes the most significant findings for the information of ANSP and Director of Safety Regulation b) Part II The details of the inspection/audited areas; and

33 Title: ANS inspectors Handbook Manual Page 33 of 62 c) Part III Inspection/audit findings identified during the inspection/audit. Inspection/audit reports may vary depending on the type of inspection/audit but shall follow the general structure specified above Report procedures Inspection/audit findings issued to the ANSP during the physical inspection/audit pursuant to section will be left with the organization and copies included in the inspection/audit report. Where the finding required corrective action prior to the end of the physical inspection/audit, the completed corrective action form will be attached to the inspection/audit finding. Where draft findings are left with the ANSP, the word draft must be added to the form header. The inspection/audit report will be presented to the ANSP within ten working days calculated from the day of the exit meeting. Inspection/audit reports that require additional time for committee review may be given five additional days to be completed. Circumstances where this is permitted shall be specified in this manual. Any delay beyond the above time frame must be documented since the validity of the inspection/audit will be compromised if the report is not presented in a timely manner. The Director of Safety Regulation will sign the report cover letter and forward the report to the ANSP. The report will outline the procedure for responding to the findings and specify the required response time of 30 days from the time the ANSP receives the report. The report will be distributed according to procedures specified in this manual. 3.6 Inspection/Audit follow-up General Upon completion of the inspection/audit, the Director of Safety Regulation will delegate follow-up responsibilities to persons responsible for regulatory oversight of the appropriate aspect of the ANSP s operation who shall ensure that; a) the corrective action plan (CAP) and inspection/audit follow-up has been entered in the appropriate database;

34 Title: ANS inspectors Handbook Manual Page 34 of 62 b) where applicable, corrective actions required by a specific date on the corrective action section of the finding form have been completed by the date specified; and c) the corrective action plan is submitted in the appropriate time and is approved, implemented and effective in rectifying the applicable non-conformances. Inspection/Audit follow-up is considered complete when: a) the applicable Inspector/Auditor has accepted all the corrective actions; b) corrective action status has been recorded in the inspection/audit file; and c) the Director of Safety Regulation has been advised and a letter forwarded to the ANSP advising them that the inspection/audit is closed. Quality Assurance activities will be used to determine the effectiveness of inspection/audit follow up Types of corrective action Short-term corrective action This action corrects the specific nonconformance specified in the inspection/audit finding and is preliminary to the long-term action that prevents recurrence of the problem. Short-term corrective action will be completed: a) by the date/time specified in the corrective action section of the finding form; or b) per the accepted corrective action plan Long-term corrective action Long-term corrective action has two components. The first component will involve identifying the root cause of the problem and indicating the measures the ANSP will take to prevent a recurrence. These measures should focus on a system change. The second component is a timetable for the implementation of the long-term corrective action. Subject to the following paragraph, long-term corrective action will take place within 90 days and will include a proposed completion date. Some long-term corrective actions may require time periods in excess of 90 days (e.g. major equipment purchases). In this case, refer to , which explains

35 Title: ANS inspectors Handbook Manual Page 35 of 62 how to deal with inspection/audit findings both beyond 90 days and closure of findings within 12 months. Where applicable, the CAP will include milestones or progress review points at 90 day intervals leading up to the proposed completion date for each inspection/audit finding. Where the short-term corrective action taken meets the requirements for longterm corrective action, this shall be so stated in the long-term corrective action section on the corrective action form Corrective action plan submission The covering letter of the inspection/audit report will require the ANSP to submit: a) where applicable, corrective action forms for each finding requiring corrective actions by the date specified in the corrective action section of the finding form; and b) a corrective action plan addressing all other findings within 30 days from the date of receipt of the report. This deadline will not be extended without the approval of the Director of Safety Regulation The Director of Safety Regulation will include the name(s) of the person(s) to whom the corrective action plan shall be sent in the inspection/audit report covering letter. Corrective action plans received from the ANSP should include completed corrective action forms and where applicable, supporting documentation that may take the form of technical record entries, purchase orders, memoranda, revised inspection/audit procedure cards, manual amendments, etc Corrective action acceptance Where the corrective action plan is acceptable, the ANSP shall be so advised and the appropriate information (administrative/on-site follow-up, proposed completion date) will be entered on the corrective action form or where applicable, the corrective action tracking form, for the purpose of follow-up. Functional databases should also be used to track the progress of inspection/audit follow up. Before accepting plans for findings that include long-term corrective actions exceeding 90 days as permitted in , the Director of Safety Regulation must be satisfied that the proposed corrective action is reasonable and that safety will not be