Inspection, Surveillance Policy and Procedure Manual

Flight Safety Standards Department Inspection, Surveillance Policy and Procedure Manual Reference: Issue: 2 Copy Number: Holder: Date: June, 2013 1

PREFACE The Inspection and Surveillance policy and procedures manual has been prepared for use and guidance of CAAN officers in the performance of their duties with respect to the surveillance requirements. It is designed to provide foundation for promoting safety through regulation and a proactive safety oversight system, as envisioned. The provision of this manual shall apply to the inspection and surveillance activities on all operators, service providers and other organization approved by CAAN. All subject matters pertaining to officers/ Inspectors of Flight Safety Standards Department, regarding inspection and surveillance, their duties, responsibilities and procedures have been covered to the extent possible. Officers/ Inspectors are expected to use good judgment while dealing with the matters where specific guidance is not available. The manual will be updated from time to time based on suggestions / inputs received. Ratish Chandra Lal Suman Director General 2

Table of Content Page 1. Overview of CAAN 1.1 Introduction 7 1.2 Organization 7 1.3 Functions 8 1.4 Amendment procedure of Manual 8 1.4.1 Responsibilities for Amendment 9 2. Responsibility of Inspection and Surveillance 2.1 Introduction 11 2.2 Responsibilities of Airworthiness & Operations Officers/ Inspectors 11 2.3 Responsibilities of the chief of Flight Operations Division (FOD), Airworthiness Inspection Division (AWID) & Licencing and 3. Inspection Examination Division (LED) 12 3.1 Introduction 13 3.2 Duties of various Divisions 13 3.3 Inspection authority 13 3.4 Inspection Procedure 13 3.5 Seizure, Retention & Return of evidence 14 3.6 Detention & Return of Aircraft 15 3.6.1 Authority of Detention 15 3.6.2 Procedure for Detention and Release of Aircraft 15 4. Surveillance 4.1 Introduction 17 4.2 Objective of Surveillance 18 4.3 Functions of various Division 18 4.4 Implementation 18 4.5 Surveillance Procedure 19 4.6 Officers/ Inspectors flying as passengers 19 4.7 Responsibilities of Officers/ Inspectors carrying out surveillance 20 3

4.8 Reporting 22 4.9 Reporting channels of Surveillance activities within ASD 22 4.10 Surveillance Procedure Review 23 4.11 Conflict of Interest 23 5. Resolution of Safety Concern 25 6. Safety Information Analysis 6.1 Introduction 27 6.2 Recording & Preserving Occurrence Reports 27 7. Monitoring Deficiencies 7.1 Procedure for Monitoring Deficiencies 29 7.2 Monthly Review of Deficiencies 29 7.3 Generation of Computer Data for all Deficiencies 29 7.4 Deficiencies recording in the form of files 29 8. Monitoring of Surveillance Activities 8.1 Assessment of Surveillance Activities 31 9. Spot check and Night surveillance Inspection 33 10. Training 35 Appendix 'A' Checklist for Nominated Person appointed by Director General for Surveillance Activity Review 37 Appendix 'B' Spot check /Night Surveillance Check 39 4

PAGE EFFECTIVITY LIST Page No. Date Rev Page No. Date Rev Page No. Date Rev 1 June, 2013 00 2 June, 2013 00 3 June, 2013 00 4 June, 2013 00 5 June, 2013 00 6 June, 2013 00 CH 1 7 June, 2013 00 8 June, 2013 00 9 June, 2013 00 10 June, 2013 00 CH 2 11 June, 2013 00 12 June, 2013 00 CH 3 13 June, 2013 00 14 June, 2013 00 15 June, 2013 00 16 June, 2013 00 CH 4 17 June, 2013 00 18 June, 2013 00 19 June, 2013 00 20 June, 2013 00 21 June, 2013 00 22 June, 2013 00 23 June, 2013 00 24 June, 2013 00 CH 5 25 June, 2013 00 26 June, 2013 00 CH 6 27 June, 2013 00 28 June, 2013 00 CH7 29 June, 2013 00 30 June, 2013 00 CH 8 31 June, 2013 00 32 June, 2013 00 CH 9 33 June, 2013 00 34 June, 2013 00 CH 10 35 June, 2013 00 36 June, 2013 00 Appendix A 37 June, 2013 00 38 June, 2013 00 Appendix B 39 June, 2013 00 5

RECORDS OF REVISION Revision No Date of Revision Incorporated By Date Incorporated 6

Chapter 1 Overview of CAAN 1.1 Introduction The (CAAN) is the principal regulatory body in the field of civil aviation. It is responsible for regulation of air transport services to/from and within Nepal, formulation and enforcement of civil air regulations, air safety and airworthiness standards, and also co-ordinates all regulatory functions with International Civil Aviation Organization (ICAO). 1.2 Organization CAAN was established as an autonomous regulatory body on 31 st December, 1998 with Civil Aviation Authority of Nepal Act 1996 and it has its Head office in Babarmahal, Kathmandu, Nepal.The organization chart of CAAN is given below: 7

1.3 Functions The main functions of CAAN are as follows:- i) Regulation of air transport services to/from and within Nepal in accordance with the provisions of the Civil Aviation Regulations, 2002, including bilateral and multilateral agreements with foreign countries and the policy pronouncements of the Government; ii) Registration of civil aircraft; iii) Laying down airworthiness requirements for civil aircraft registered in Nepal and grant of Certificate of Airworthiness to such aircraft; iv) Licensing of pilots, aircraft maintenance engineers and monitoring of flight crew standards; v) Licensing of aerodromes and air carriers; vi) Rendering advice to the Government on matters pertaining to civil aviation; vii) Processing amendments to Civil Aviation Act, 1959, Act, 1998 and the Civil Aviation Regulations 2002, and other Acts relating to aviation, with a view to implementing in Nepal the provisions of the Chicago Convention and Annexes thereto and other International Conventions relating to aviation; viii) Co-ordination of the work relating to International Civil Aviation Organisation and sending replies to State letters after consulting other agencies; ix) Investigation of air accidents and incidents and rendering technical assistance to the Courts/Committees of Inquiry; x) Supervision of training activities of Flying/Gliding Clubs, Development of light aircraft, gliders and winches; xi) Validation of Type certification of aircraft; xii) Licensing of Air Traffic Controllers; and xiii) Certification, inspection and regulation of communication, navigation and surveillance or air traffic management facilities. 1.4 Amendment Procedure of Manual All amendments to this Manual shall be issued by Flight Safety Standards Department, this office under the process and responsibilities for amendment as and when the Inspection and surveillance policies and procedures are revised or modified. These revisions upon approval from Director General supersede the related policy as stated in this Manual been issued. 8

1.4.1 Responsibilities for amendment CAAN Officers/Inspectors (REVIEW Team) Chief of AWID, FOS, FSLD Suggest changes that would improve the efficiency and effectiveness of procedures. Review the amendment in accordance with Rules, Regulations or established Procedures. Forward the vetted draft to the chief of division. When approved by Director General, arrange for incorporation in accordance with document control procedures. Monitor compliance with procedures and gives feedback. Recommend the amendment in the area of responsibility. Director / DDG Vets the proposed amendment. Director General Considers the suggested amendment Takes final decision and introduces the amendment. 9

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2.1 Introduction CHAPTER 2 Responsibility for Inspection and Surveillance Nepal being one of the contractual signatories to the convention on International Civil Aviation and a member of the International Civil Aviation Organisation (ICAO), has an obligation to promote safe, orderly and efficient operation of aviation activities. To meet state obligations, CAAN has developed a system of surveillance to ensure that the standard maintained at the time of issue of aviation documents, such as approval certificate, licence, rating, etc. is maintained throughout the validity period. Therefore, primary responsibility of the CAAN is Safety Oversight, and to meet this obligation, Flight Safety Standards Department has prepared an Annual Surveillance Program (ASP) in respect of all the Division. FSSD ensure effective monitoring of the Inspection and surveillance program. Any Inspection and surveillance action to be taken by officers/ Inspectors should clearly and unambiguously be covered by the legal authority available to them. Therefore, only officers/ Inspectors with valid and current delegation shall exercise the authorities within the confines of instrument of authorization. 2.2 Responsibilities of Airworthiness and Operations officers/ Inspectors Without limiting the scope of tasks which Airworthiness and Operations officers/ Inspectors may be asked to perform in relation to variation, suspension or cancellation action, it shall be the responsibility of Airworthiness and Operations officers/ Inspectors to - a) gather or receive the information and evidence, which supports a recommendation for an action; b) seek advice and input from the relevant Division, such as Flight Operation Section, Airworthiness Inspection Division, Flight Safety and Licencing Division in relation to the conduct of the operator/person in question; c) complete a non-compliance report and forward it to the appropriate Division in FSSD recommending a proposed course of action; d) assist the concerned Division by providing information and advice, as necessary; e) serve or arrange for the service of the relevant notice to the person affected; f) give an opportunity to the affected person to give his version orally or in writing; g) take any follow-up action that may be necessary (including the provision of airworthiness and operational assistance) action or litigation; and h) provide any other information or take any other action, as deemed necessary. 11

Inspection, Surveillance Policy and Procedure Manual 2.3 Responsibilities of the chief of Flight Operation Section (FOS), Airworthiness Inspection Division (AWID) and Flight Safety and Licensing Division All chiefs such as are the senior delegates who shall- a) ensure that their Division are organized, staffed and equipped to perform the assigned functions and duties; b) lay down the administrative procedures for the Officers/Inspectors in order to ensure their smooth and efficient functioning; c) supervise the safety oversight activities of the Officers/Inspectors; d) liaise with the operators to ensure smooth and efficient execution of the safety oversight functions; e) ensure that the safety oversight activities conform to rules, regulations and procedures laid down by the CAAN; f) submit periodic and other analytic reports to the Director General of the results of the inspections; g) ensure that the Officers/Inspectors carry out refresher training regularly; i) ensure that Officers/Inspectors hold credentials, necessary authorizations and provided with handbook, checklists and all the tools and amenities needed; j) liaise with the other Departments in CAAN and provide them with specialized advice on all operational matters; k) advise on all matters relevant to their divisions; l) keep the Director General informed of all important activities of their Division; m) ensure that the objectives of the inspections are met and that the system of inspection is updated, optimized and institutionalized to meet the changing situations; and n) update CAAN records about the operator s compliance with the applicable requirements. 12

3.1 Introduction Chapter 3 Inspection Inspection which is a key element of any safety oversight function, involves examination or observation of operator s actual performance, aviation documents, aircraft, cargo, premises, aeronautical products such as appliances, parts and components and facilities relating to aeronautics. The purpose of inspection is to determine whether compliance with regulations and standards is being maintained, in relation to the approved provisions in the Operator s Manual. 3.2 Duties of various Divisions As a part of their duties, the following activities shall be performed by various Division:- a) Flight Operation Division (FOD) conducting airline inspections, audits in regards to operation matters. b) Flight Safety Licensing Division Conducting and scrutinizing the examination results, Issuance of Crew Licence. c) Airworthiness Inspection Division conducting audits and inspection of aircraft, Aircraft Maintenance Organisations (AMO) and Licensing of Aircraft Maintenance Engineering. 3.3 Inspection Authority An inspection may be conducted by Officers/Inspectors in pursuant to the powers conferred by various provisions of the Civil Aviation Act 1959, Act 1996 and Civil Aviation Regulations 2002 These provisions provide for the following:- (i)entry into aircraft, aerodromes, facilities or premises at all reasonable times; (ii)production of records and documents; and (iii)inspection and search for the purpose of securing compliance with the provisions of the Civil Aviation Act 1959, Act 1996 and Civil Aviation Regulations 2002 3.4 Inspection Procedure When conducting routine inspections for the purpose of determining compliance, Officers/Inspectors shall observe the following:- i) Inspection should be conducted at a time that minimizes inconvenience to flight crew, owner/operator and the travelling public; ii) Officers/Inspectors shall not enter aircraft or premises which are locked or where the owner/operator or appointed representative is not present; iii) They shall use credentials card for personal identification. They should also wear the airport entry permit, iv) The flight crew and owner/operator of an aircraft shall be informed about the inspection. Notifying the Pilot-in-Command or Station Manager is considered sufficient for this purpose. This can be done either by phone or by having met them in the aircraft; 13

v) A document produced for the purpose of inspection should be kept no longer than is necessary to determine its validity; vi) Where the validity of a document cannot be determined readily, a photocopy, photograph, accurate record or facsimile of the entries or endorsement on both sides of the document should be made before returning the document; vii) Officers/Inspectors may seize relevant and appropriate evidence with respect to a contravention discovered during the course of a routine inspection; viii) If an unsafe situation is discovered, the Pilot-in-Command or aircraft representative shall be informed and the inspector shall decide whether or not immediate detention of the aircraft is required; ix) Inspections should be completely documented with notes recorded sequentially in the Inspector s Handbook including dates and times; and x) In the event of any obstruction to an inspection, the Officer/Inspector should politely inform the individual of the purpose of the inspection, the authority granted for performing the inspection, and that the individual is obstructing the conduct of this inspection. If this does not gain cooperation, the Officer/Inspector shall explain that obstruction is an offence, and that a charge could be laid under the rules for obstructing an inspection. Should the individual continue to obstruct the inspection, the inspection should be abandoned and report the same to chief of the respective division. The chief of the division will report the same to the Director of FSSD, who will act in accordance with the provision laid down in Civil Aviation Regulations 2002. 3.5 Seizure, Retention and Return of Evidence Where evidence is seized, the Officer/Inspector shall ensure that - i) the holder is given a receipt; ii) the evidence is clearly marked in an identifiable manner; iii) reasonable care is taken to preserve and protect the evidence; and iv) continuity of possession of evidence is assured. Where an Aircraft Journey Log Book is seized, a Temporary Aircraft Journey Log Book can be issued. The Temporary Log Book must contain a statement that the original has been seized. Alternatively, a photocopy of the log book properly identified as a certified true copy and signed by the owner, the inspector or the investigator is acceptable. Before making a photocopy, the original should be marked in a uniquely identifiable manner to preclude alteration or substitution; and the evidence is returned to the person from whom it was seized or who has lawful entitlement to it as soon as practicable when continued retention is not required for the purposes of any investigation, hearing or other similar proceeding. Evidence must be returned within 30 days of seizure and the receipt mentioned above be cancelled if i) there is no dispute as to who is lawfully entitled to it; ii) return is not likely to affect aviation safety; and iii) it is no longer required. 14

Inspection, Surveillance Policy and Procedure Manual 3.6 Detention and Return of Aircraft 3.6.1 Authority for Detention As per Civil Aviation Act Aircraft Act, 1959, and Civil Aviation Regulations, 2002, Officers/Inspectors may detain any aircraft, if in the opinion of such Officer/ Inspectors a) having regard to the nature of an intended flight, the flight of such aircraft would involve danger to persons in the aircraft or to any other person or property; or b) such detention is necessary to secure compliance with any of the provisions of the Aircraft Act or the rules applicable to such aircraft; or c) such detention is necessary to prevent a contravention of any rule or to implement any order made by any Court. 3.6.2 Procedure for Detention and Release of Aircraft When Officers/Inspectors contemplate the detention of an aircraft, they must introduce themselves to the Pilot-in-Command or owner/operator and specify the unsafe condition or unsafe operation which they believe exists or is likely to exist. They should tactfully try to obtain voluntary compliance in correcting the situation. If unsuccessful, the Officers/Inspectors shall - i) again advise the Pilot-in-Command or owner/operator of the unsafe condition or operation and the consequences of failing to abide by the inspector's advice (e.g. detention and/or enforcement action); ii) where the Pilot-in-Command or owner/operator is unavailable or indicates an unwillingness to comply with the inspector's advice, attach to that part of the aircraft most likely to be seen by the flight crew a written notice of detention specifying the unsafe condition or operation; iii) if necessary, restrain the movements of the aircraft- a) by requesting ATS deny taxi and take-off clearances; or b) by blocking it with vehicles; or c) by attaching it to an immovable object; or d) in extreme cases, and with the assistance of a licensed Aircraft Maintenance Engineer, by judicious and temporary disablement, a record of which must be made in the aircraft log. Whenever possible, an aircraft shall be detained without removing it from the custody of its owners or operators. This will permit such persons to make repairs or otherwise remedy the unsafe situation. However, if no other measures have been or are likely to be effective in alleviating the unsafe condition or operation, the aircraft may be taken into the custody of the CAAN. In such cases, all reasonable care shall be taken to preserve and protect the aircraft in the condition in which it was first acquired. The aircraft should be released if it will not be operated or if it will be rendered airworthy before operation and will not be operated in an unsafe manner. The decision to release the aircraft shall be taken by an officer senior to the one who had detained the aircraft. Therefore, details concerning the detention should be forwarded to the appropriate supervisor for a decision on the release of the aircraft from detention. 15

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4.1 Introduction CHAPTER 4 Surveillance The purpose of surveillance is to determine whether compliance with regulations and standards is being maintained, in relation to the approved provisions in the Operator s Manual or exposition required to be submitted (for acceptance/approval by CAAN) under the entry process, and maintained during the validity of the certificate. The rules place emphasis on this exposition and the management and quality assurance systems that show how the organisation will stay in compliance. In this connection, it is vital to keep in mind the difference between compliance and enforcement. Compliance consists of all regulations and safety standards being met. When compliance exists, there is no need for enforcement. Enforcement is the action necessary when compliance is not present. Enforcement requires legal or administrative action. During the surveillance the focus is on checking what is being done, against what the organisation says it will do, as set out in the manual(s). The procedures set out in the organisation s manual will be a combination of those required to maintain compliance with regulatory (minimum) standards, and those arising from company (additional) standards activities. A deviation from procedures required to maintain compliance with the minimum standards is a finding of non-compliance, and a finding of non-conformance in other cases, and the corrective action will be determined accordingly. A vital part of this aspect is to achieve uniformity, transparency and consistency of action. Similar conduct under similar circumstances should result in the same type of action. At the same time, it also requires the Officers/Inspectors to make every effort to understand a person s position and take it into account, as well as to let the person know the CAAN's position. There should not be a rigid adherence to precedent without due regard to unusual circumstances. Many factors are considered in choosing an appropriate course of action to ensure compliance and provide deterrence to breaches of regulatory requirements or procedures. The weight given to various factors often is left to the discretion of the individual officer/inspector. In the exercise of his discretion, the Officer/Inspector should be guided by the following general approach:- A person who reports making an honest mistake should generally not be prosecuted or fined, nor should their license, certificate or authority be suspended or cancelled for reasons of punishment. There should be a measured response to less serious contraventions of the safety rules and procedures which may involve counseling and training rather than either criminal prosecution or the suspension or cancellation of license, certificates or authorities or imposition of any monetary penalties. People who consciously and willfully choose to operate outside the rules or procedures and thereby put the lives of members of the public including the passengers or property at risk should be prosecuted and removed from the industry. 17

4.2 Objectives of surveillances The surveillance programme shall be prepared with the aim of achieving the following objectives:- i) promotion of compliance by the establishment of regulatory presence; ii) conduct of investigations; iii) detection of contraventions; iv) promotional and educational activities; v) liaison with detection sources; vi) information gathering; and vii) targeted surveillance. 4.3 Functions of various division with respect to surveillance activities In carrying out the surveillance function, each Division of FSSD has the following broad responsibilities: (i) Develop an Annual Surveillance Programme (ASP) for each year related to their area of surveillance and submit it to Director of FSSD by end of year, (ii) Develop a checklist for surveillance area giving reference of regulations to applicable be complied with schedule surveillance activities, assigning officers and resources, (iii) Maintain records of surveillance activities/create Data Base, (iv) Follow up implementation and closure of corrective actions by tracking mechanism, (v) Recommend regulatory action where necessary to ensure compliance with the rules, (vi)report on the performance of surveillance every month. (vii) Attend the surveillance monitoring meeting to represent their surveillance programme as organized by Director, FSSD. 4.4 Implementation The implementation of a safety oversight surveillance programme is concerned with satisfying the CAAN objectives of regulatory presence, investigation, detection of contraventions, compliance, promotion and education. Generally, the surveillance shall be carried out overtly by the Inspector introducing them to the operator/organization and also giving the purpose of surveillance. This helps to promote voluntary compliance of the requirements. Surveillance is carried out wherever and whenever aviation activity is most likely, including weekends and evenings. To the extent possible, it should cover a cross-section of all operations taking place in the respective field. It must be ensured that each surveillance team - (a) is composed of Officers/Inspectors whose specialty is pertinent to the type of the 18

surveillance activity; and (b) is fully qualified, duly authorized and properly briefed for the operation. 4.5 Surveillance Procedure The most effective method of performing safety oversight functions and enhancing safety within the aviation community is to prepare a structured surveillance programme which should be implemented vigorously. Surveillance may be either routine or special-purpose. The purpose of surveillance is to provide a regulatory presence to promote voluntary compliance and reveal contraventions of the legal provisions. The probability of being detected is one of the most powerful compliance motivators. When a comprehensive and effective surveillance programme is in place, a higher degree of compliance and flight safety can be expected. Routine surveillance, which includes surveys, audits, base inspections, organisation/permit renewal inspections, and ramp checks, is conducted during the normal course of the Officers/ Inspectors duties of monitoring day-to-day aviation activity. When contraventions of regulations are detected, Officers/Inspectors are responsible for completing the detection process for submission to the concerned chief of the division. These contraventions, collated and analyzed at the senior level, may reveal problems, trends or threats to aviation safety. Planned surveillance is directed at specific areas, events and activities in support of annual surveillance plan, which shall be prepared in the last month of the year for the purpose of surveillance to be conducted during the next year, which will also be notified on the CAAN website. The Checklist for Audit of an organization is given in Flight Operations and Airworthiness Inspector Handbook. The Checklist to perform Ramp inspection for domestic carrier, International Airlines (registered in Nepal) is given in Flight Operations and Airworthiness Inspector Handbook. The Checklist to perform Ramp inspection of Foreign Carrier is given in Foreign Carrier Surveillance Procedure Manual. Officers/Inspectors shall make use of the Inspector s Handbook or a similar document provided by the CAAN for this purpose. Where appropriate, photographs may be taken. The primary objective should be to watch for any regulatory contraventions and wherever possible, prevent a contravention by dealing with the cause beforehand. Usually a friendly approach emphasizing the safety element can bring about voluntary compliance with the regulations. 4.6 Officers/Inspectors Flying as Passengers If Officers/Inspectors, while flying as passengers on an airline either on duty or off duty, detect a contravention which, in their judgment, must be brought to the attention of the flight crew (e.g. a major disregard of the Rules and Regulations), they shall contact the Pilotin-Command after the flight has terminated. After identifying themselves, the Officers/Inspectors shall indicate to the Pilot-in-Command the nature of the contravention and advise him that a detailed written report shall be made in this regard. Reporting regarding this matter shall be done to chief of the division and director of FSSD without delay. It shall contain sufficient details including all available evidence to allow follow-up action. The policy of post-flight notification does not apply where the contravention compromises flight safety. In such a case, direct and immediate action shall be taken by the Officer/Inspector. Upon reporting to the chief of division and Director of FSSD, they will assign an investigator to the case. Both the reporting officer and assigned investigator shall continue to coordinate their work as necessary until the conclusion of the case. 19

4.7 Responsibility of the Officers/Inspectors carrying out surveillance:- i) Intimate the organization of the CAAN surveillance plan at least 7 days in advance of the officer's visit. On request from the organization, the dates of inspection may be deferred by a week, and another suitable date intimated. If this is also requested for deferment, a third date should be given. Any further request for postponement should not be agreed to and the surveillance to be carried out on dates finally intimated. If the inspection is not allowed by the organization, it should be reported to respective chief of the Division, who will further report to Director, FSSD. Director of FSSD will report it to Director General as level 1 finding for immediate action. ii) The assigned officers should familiarize themselves with the reference regulation in a thorough manner. The officer should study a) Applicable regulations, CARs, / CAAN circulars etc. b) Company procedures / naturals. c) Previous audit(s) / Inspection reports (at least two previous reports must be studied and actions taken by organization to close all previous findings should be noted). d) Applicable checklist should be updated with any changes in the regulations / manuals and customization notes for the specific organization should be prepared. e) The division specific information with respect to area of surveillance such as ADs, MMEL revision no., manufactures latest instruction with regard to AMM revision etc should be noted prior to commencement of audit. It is expected that the study and familiarization with the organization specific material will take 2-3 days prior to the surveillance date. Chief of concerned Division should ensure that the surveillance team is relieved of extraneous office duties to enable them to prepare for meaningful surveillance. 1. The surveillance shall be started with a meeting of Accountable Manager / Post Holder with the Audit Team. 2. Surveillance shall be carried out with the use of customized audit checklist available in Flight Operation and Airworthiness Inspector Handbook. 3. Observations made during surveillance shall be recorded against each item of audit check list. 4. The completed deficiency reporting form (DRF) should then the forwarded to the concerned operator/organization for necessary corrective action. 5. After receipt of notification of findings, the approved organization shall define a corrective action plan and demonstrate corrective action to the satisfaction of the CAAN within a period depending upon the level of the finding. 6. On receipt of such form from the operator / organization, CAAN officers/ Inspectors shall review the target date depending upon the level of deficiency for corrective action before acceptance of the same. 20

7. All organizations shall take prompt action of resolving the non-conformities brought out during the surveillance inspection, spot checks or safety audits conducted by CAAN Officers/ Inspectors. 8. Time period for compliance shall be counted from the next calendar day of the date of raising the DRF. 9. Where the organization fails to implement the corrective action after the time period agreed with CAAN, the FSSD will forward the non-compliance report to Director General for consideration with appropriate recommendation. 10. Where no reasonable and justified reasons are assigned for nonimplementation of the corrective action plan within the time frame agreed upon with CAAN, necessary enforcement action will be initiated against the organization or the person responsible for noncompliance as the case may be. 11. The time periods as specified above supersede any other time periods specified in any other applicable rules and regulation. Variation of the time periods for compliance shall only be with the approval of the Director General. 12. A monthly program of Audit is also prepared by divisions of FSSD which covers Scheduled & Non scheduled operators. A monthly progress report of ASP will be submitted by chief of concerned division to Director of FSSD. In the process of ensuring compliance, the officers shall invariably be guided by the following principles:- a) Natural Justice and Accountability: Decisions of Officers/ Inspectors must be - i) fair and follow due process of law; ii) transparent to those involved; iii) consistent between like circumstances; and iv) subject to appropriate internal and external review. b) Impartiality: Decisions of officers/ Inspectors must not be influenced by - i) personal conflict or agendas of the officers; ii) irrelevant considerations, such as gender, race, religion, political views or affiliation; or iii) personal, political or financial power of those involved. c) Proportionality: Decisions of Officers/Inspectors must be commensurate with the identified breaches and the safety risk they give rise to, in particular - i) CAAN s first priority shall be to protect the safety of the members of the public including fare-paying passengers; ii) CAAN shall take strong action against those who consistently and deliberately operate outside the existing law or approved Procedures; iii) CAAN shall endeavour to educate and promote training or supervision of those who are observed to be lacking in proficiency but are willing to comply; 21

Inspection, Surveillance Policy and Procedure Manual iv) CAAN shall take action when dealing with licensed and certified personnel, who breach the Rules, Regulations and Requirements etc. 4.8 Reporting At the conclusion of the surveillance activity, a detailed report shall be prepared and submitted to the concerned chief of the division, who shall forward the same to the Director of FSSD. The report shall include the evidence that has been gathered in support of the contraventions as well as an account of all actions taken. 4.9 Reporting channels of surveillance activities within FSSD The reporting is done to the officer higher up in hierarchy. Flight Safety Standards Department Director Chief Flight Operation Division Chief Airworthiness Inspection Division Chief Licencing & Examination Division Dy. Director Dy. Director Dy. Director Manager Manager Manager Ast. Manager Ast. Manager Ast. Manager Sr. Officer Sr. Officer Sr. Officer 22

4.10 Surveillance Procedure Review A review of ASP/Audits will be held time to time as organized by Director, FSSD. Wherein monthly progress, shortfalls against monthly targets / problems faced etc; will be analyzed by Director along with analysis of identified deficiencies categorized into level I & II. A level I finding is any significant non-compliance with applicable CAAN requirements which lowers the safety standard and hazards seriously the flight safety. A level II finding is any non-compliance with the Applicable CAAN requirements which could lower the safety standard and possibly hazard the flight safety. For level 1 findings, immediate action shall be taken by CAA Nepal to revoke, limit or suspend in whole or in part, depending upon the extent of the level 1 finding, the approval, until successful corrective action has been taken by the organization. For level 2 findings, the corrective action period granted by CAA Nepal must be appropriate to the nature of the finding but in any case initially must not be more than three months. In certain circumstances and subject to the nature of the finding CAA Nepal may extend the three month period subject to a satisfactory corrective action plan agreed by CAA Nepal. These deficiencies will be fed into the ASP Data Base for resolution, tracking and dissemination of safety related issues. The Director, FSSD in turn forward these matters to Director General. 4.11 Conflict of Interest Officers/Inspectors are required to take measures to prevent real, potential or perceived conflict of interest in accordance with the principles enshrined in the conduct rules. If it becomes apparent that there could be a possible conflict of interest during an surveillance, the Officer/Inspector shall inform his or her supervisor with the request to be removed from the case. 23

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CHAPTER 5 RESOLUTION OF SAFETY CONCERNS For effective implementation of surveillance programme, it is necessary that surveillance carried out by officers/ Inspectors of various divisions should be monitored at higher level. Therefore, a meeting is conducted with a chairmanship of Director General with presence of Deputy Director General, Director of FSSD, Chief of all divisions of FSSD with the objective to resolve category level I safety deficiencies in a timely manner. In addition to above the meeting will also review the following:- 1. Cases where significant non compliance occurs with the applicable requirement which lowers the safety standards and hazards seriously the flight safety. 2. Cases of violations to the Civil Aviation Regulations and requirements and other CAAN Directives. 3. Repetitive findings which could lower the safety standards and could possibly hazard the flight safety. 4. Other deficiencies if not rectified within the stipulated time period. 5. Cases put up under Appeals. 6. Review of recommendations of Courts of Inquiry and similar safety recommendation. 7. Important incidents to all aircraft and 8. Other Important safety issues. The cases under consideration are presented by the chief of concerned Division and discussed in the Meeting. The decisions of the meeting are minuted and conveyed to the participants and concerned division for taking effective action. 25

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6.1 Introduction CHAPTER 6 SAFETY INFORMATION ANALYSIS For the purpose of Safety Information Analysis, information is needed to Flight Safety Standards Department, for pro-active actions for strengthening and enhancement of aviation safety requires no emphasis. Utilization of safety related information and taking corrective actions for future is one effective way to promote safety. For that reason, 1. Safety related information is furnished to Director of FSSD from various sources such as VIRS, airlines, aerodromes etc. These information relate to Incidents / Occurrences (also referred as Troubles) which may have affected operations of aircraft and also have potential of converting into serious affected / accidents in future if pro - active actions are not taken by the concerned and also other stake holders (as per iceberg theory). 2. Notification of accidents / serious incidents / incidents should be informed to Director of FSSD as soon as possible 3. In cases of accidents / serious incidents / incidents where formal investigations are ordered by Ministry/ CAAN, recommendations are generated for action by concerned stake holders. Likewise, Internal Investigation carried out at the level of airlines etc. also produces recommendations pertaining to cases falling in their jurisdiction. Cases of such occurrences, their analysis and corrective actions and, in particular, trends shall be disseminated to the industry in de -identified form for sharing and proactive action at their end to prevent recurrence of such troubles in their organizations. 6.2 Recording and Preserving Occurrences Reports (i)reports received will be categorized under following categories: - Engineering / Maintenance troubles. Human Factors Operations Ground Handling Runway incursion, FOD etc. Bird Hit Misc. (ii) Compile month-wise occurrences, analyze, determine trends occurrence wise, de-identify and disseminate useful information to all stakeholders as a periodic bulletin. (iii) A safety information database on the basis of(i) above will be generated. (iv) Each operator will be required to fully utilize the information shared with them 27

by CAAN. (v) Records are preserved in Hard copy and soft copy at the Flight Operations and Airworthiness Records. 28

CHAPTER - 7 MONITORING DEFICIENCIES 7.1 Procedure for monitoring deficiencies All deficiencies observed during surveillance carried out by various officers/ Inspectors are required to be forwarded to concerned chief of division. The chief of division will examine level of the deficiencies and forward a report to the Director of Flight Safety Standards Department. 7.2 Monthly Review of Deficiencies All the offices/ Inspectors are required to intimate concerned chief of division immediately, whenever they observe any Level I finding while carrying out their surveillance programme. These Level I findings will be examined in the meeting chaired by Director General in presence of DDG's, Director of Flight Safety Standards Department, Chief of Divisions If there is any emergency, the meeting can be held immediately to resolve Level 1 discrepancies. All Level I discrepancies are discussed in the meeting, to take a view on the action to be taken against the concerned organization/personnel. Records of Level I findings and action taken are being maintained by the respective Division of the FSSD. 7.3 Generation of computer data for all deficiencies All divisions of Flight Safety Standards Division stores data relating to monitoring of Level I and Level II deficiencies. After surveillance the deficiencies are being fed into computer. The system is capable of monitoring open and close deficiencies of organizations/ operators wise. 7.4 Deficiencies record in the form of files All divisions of Flight Safety Standards Department shall also maintain manual record in the form of files of all the deficiencies observed while carrying out surveillance of organizations/operators. These records/files cover the following organizations/operators:- 1. Scheduled/non-scheduled operators 2. Approved organisations related to airworthiness 3. Flying training institutes 4. Foreign operators The database, records/ files shall have following information 1. Surveillance Area 2. Organization 3. Surveillance Date 4. Regulation Reference 5. Deficiency Detail 29

6. Deficiency Closure Details. The surveillance records shall be maintained for 5 years. All divisions of Flight Safety Standards Division maintain only Level I and Level II deficiencies. It is the responsibility of each Division to ensure that open discrepancies do not exceed the time limit determined by CAAN from time to time. 30

Chapter 8 MONITORING OF SURVEILLANCE ACTIVITIES 8.1 Assessment of surveillance activities In order to ensure that surveillance inspections are carried out as per Annual Surveillance Program (ASP) and proper procedures are followed for grading findings as Level I or Level II, surveillance records are maintained properly and closure actions of deficiency reporting form are taken after due completion of all actions, it is necessary that assessment of surveillance activity of various Division are carried out by Qualified nominated person appointed by Director General for this task. To achieve the above objective a quarterly plan shall be prepared by all the division with the approval of Director of FSSD. As a matter of procedure the Director General shall appoint the Nominated person who shall intimate the chief of all the divisions about their plan to carry out assessment at least seven days in advance. The Nominated person must use the check list (Appendix A ) for conducting the assessment and also provide or refer to the checklist to be used in the assessment. A compliance report of the checklist may be asked for. This will ensure that the desired areas / activities have been looked into fully by the assessor and all records updated to facilitate assessment. The Nominated Person should submit the assessment report along with the checklist duly completed to Director General within one week of the completion of the assessment. 31

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Chapter 9 SPOT CHECK & NIGHT SURVEILLANCE INSPECTION In order to enhance safety of operation and to maintain higher standard of continued oversight of operators, all Divisions are required to carry out spot check and night surveillance inspections ensuring that the activities carried out by various operators / organizations during the Maintenance are meeting the desired level of standards. The purpose of such inspection is also to ensure that operators do not shortcut any procedures, deployment of necessary manpower, release of aircraft without proper defect rectification, extend MELs due to absence of managerial supervision or any other reason. The operators need not be intimated for such surveillance inspections. This will make operator aware of the fact that the CAAN may conduct surprise surveillance checks also and will make operator vigilant and alert to follow the laid down procedures while conducting tasks. The surveillance inspectors must ensure that the operator has detailed adequate staff / manpower for the particular activity and the personnel use laid down procedures, updated technical data and are provided with adequate facilities for satisfactory performance of the task. The working environmental conditions, fatigue level, human factor / human performance and use of alcohol, psychoactive substance must also be checked. These are some of the areas where compromises can be made while performing the task. A standard checklist (Appendix B ) for the spot check and night surveillance may be used as a guideline by various Divisions while carrying out spot check and night surveillance. Respective Divisions must also have Spot check and night surveillance checklist for specific area of activity / task for the operator and enclose the same for effective and standardization of spot check and night surveillance checks. The reports of spot check and night surveillance shall be submitted by all divisions to Chief of their respective divisions. 33

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CHAPTER 10 TRAINING Training is essential to understand working procedures of the surveillance activities. Therefore, training shall be conducted for all the officers on Procedures so that they can understand the system and carry out surveillance monitoring of the Annual Surveillance Programme and also to ensure records and procedures for their Division. Head of the Division will train all officers/ Inspectors engaged in the task of surveillance through class room training and on-job training on the following subjects:- 1. Objective of the surveillance programme 2. Responsibility of various divisions 3. Preparation of Annual Surveillance Programme (ASP) 4. Surveillance Procedures 5. Follow up action of observations 6. Procedure for enforcement action 7. Monitoring of surveillance programme & action taken 8. Maintenance of records of surveillance and action taken 9. Compilation of surveillance records 10. Presentation in the monthly surveillance meeting. 11. Follow up action and record keeping in respective division 35

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(APPENDIX A ) Check List for Nominated Person by Director General for Surveillance Activity I. Audit Composition 1. Name of Division 2. Team Member(s) (Names & Designations) 3. Area(s) to be audited 4. Date of Audit II. Guidelines for conducting Assessment 1. Intimation to the assessee 2. Forwarding of checklist for assessment of surveillance to the assessee 3. Receipt of compliance of checklist from the assessee. III. Items to be Assessed 1. Check for any previous audit findings pending 2. Check for availability of Current year ASP for the office 3. Check availability of Surveillance Procedure Manual and familiarity of all concerned with the same 4. Check availability of Enforcement Manual, Circular and familiarity of all concerned with the same 5. Check for the Procedure Manual for Conducting Surveillance 6. Availability for Database for Surveillance 7. Check Implementation of ASP 2011 No. of Surveillance Planned Month wise a. No. of Surveillance carried out Month wise b. No. of Surveillance Pending Month wise with reason and when scheduled 8. Check Deficiency detected are raised on deficiency reporting form No. of deficiency reporting form raised Month wise a. No. of deficiency reporting form closed Month wise b. No. of deficiency detected Level I. Level II. c. No. of deficiency pending > 1 month d. No. of deficiency pending > 2 month e. Intimation to the concerned 9. Check Whether deficiency reporting form reflects regulation reference of the findings 10. Check whether Findings have been properly classified as level I/II 11. Check action taken on Level I/II findings 12. Check for the quality of closure of deficiencies reporting form by next level official 13. Check the procedure followed for monitoring of findings which are open 14. Check for surveillance records 15. Check Enforcement Action taken 16. Any other observation/ Area covered during Audit 1. 2. 3. 37

IV. Summary-Analysis/ Synopsis of Surveillance Activity Review Signature of Assessees Signature of Assessor 1. 2. 3. 38

Flight Safety Standards Department (APPENDIX B ) I. Audit Composition 1. Name of Division 2. Team Member(s) (Names & Designations) 3. Area(s) under Surveillance 4. Date of Surveillance II. Guidelines for conducting Surveillance 1. Intimation to the Operator III. Items to be Checked 1. Check for sufficient manpower 2.Check validity of Licenses / certificates 3. Check for availability of Procedures / updated technical data, Tools / Equipments etc. 4.Check for adequacy of facility 5. Check for the roster. 6.Check for adequate lighting 7.Availability of Tools / Tool Kits 8.Check for use of Psychoactive Substances, alcohols etc. Spot Check/Night Surveillance Check 1. 2. 3. IV. Summary-Analysis/ Synopsis of Surveillance Activity Signature 1. 2. 3. 39