8/2/18

 

8900.1 CHG 422

Appendix 14-4. Compliance Action Documentation Review Job Aids

Indicates new/changed information.

This document consolidates the Compliance Action (CA) data reporting requirements found in Volumes 10 and 14 and the Program Tracking and Reporting Subsystem (PTRS) Procedures Manual (PPM). Policy requires documentation of who, what, where, when, and why, including the Root Cause Analysis (RCA), the corrective actions taken (or to be taken), and any necessary followup to validate that the problem is fixed.

Documentation to address seemingly simple, nonsystemic issues may be in a single PTRS; or, for the Safety Assurance System (SAS), in the Data Collection Tool (DCT) and associated assessment, or in Module 5 alone if initially identified by the principal inspector (PI) through Analysis, Assessment, and Action (AAA).

Complex or systemic issues require details to tell the whole story. For this reason, the importance of linking all of the required parts of CA records together with triggers, comments, and/or references cannot be overemphasized (e.g., referencing related entries in Modules 4 and 5 data blocks, adding references to airman or other PTRS records in SAS, and adding SAS record identifiers in PTRS).

The following phrases may help you with data consistency and quality across all databases. This template language is not mandatory and, if used, additional sentences, information, or modification may be needed to provide a complete and comprehensive report. Note that the term “certificate holder”#8221; (CH) has been used below for convenience, but you may refer to any organization or individual.

Investigation: I (notified or was notified by) (source such as individual, certificate holder (CH) personnel, Air Traffic Control, etc.) that on (date) (at place or on flight) (identify CH and additional persons involved) did not comply with (safety requirement, regulation, or statute) when they failed to (citation statement). The FAA became aware on (date).

Root Cause Analysis (RCA): This deviation was due to (list the root cause(s)).

Corrective Action: (Individual name and CH position, if applicable) corrected the (safety issue or noncompliance) when (state the corrective action and/or refer to attachment if detailed/complex).

Comments: I used (additional training, counseling, on-the-spot correction, or describe other action taken) to regain (compliance or safe operations). I (am or am not) satisfied the certificate holder’s corrective actions fully address the identified cause(s) and (have or have not) reestablished (compliance or safe operations). I recommend (no further action or additional follow-up or reexamination/reinspection or enforcement).

Documentation Tips

Use the above statements whenever possible to promote consistency and enhance data quality.

Human error is not a cause. Identify what caused the human to error (e.g., see FAA Dirty Dozen).

For regulatory issues, ask the CH to provide a RCA, then validate it and document CH and FAA analysis (help the CH develop RCA skills).

SPAS “Good SNAAP Regulations” contain prohibitive/restrictive rules and citation statements.

RCA only needs to be as detailed as the situation warrants.

Reference all communication and items of proof. Upload documents in SAS when appropriate.

The following three job aids may be useful to aviation safety inspectors (ASI), data evaluation program managers (DEPM), Front Line Managers (FLM), and others to make quality records and perform consistent reviews.

SAS Module 4 Compliance Action (CA) Documentation Review Job Aid

1.0

Data Collection Tool (DCT) Entries:

Notes

Reference

1.1

Enter data into the common data fields:

Document nonregulatory safety concerns and/or recommendations with no apparent regulatory or statutory deviation in the SAS record for the underlying activity that led to identification of the concern.

10-5-2-9A

14-1-2-7B

14-1-2-9B

 

  When did you perform this activity?

  Where did you perform this activity?

  Who were the points of contact or individuals you observed?

1.2

Document inspector actions taken to address the problem. Document Compliance Action (CA) when the inspector takes action in the “Inspector Action Taken” field (or in the “Supporting Comments” field for ED and RI DCTs):

Document “Corrected on the Spot” ASI actions in the “Inspector Action Taken” field and certificate holder actions in the “Supporting Comments” field.

10-5-2-9A

Table 10-5-2A

14-1-2-7B

14-1-2-9G

 

  What did you do to communicate the problem to the certificate holder?

  Who did you tell?

  What actions did you take to correct the issue at the point of discovery?

  What were the mitigations/CAs taken by the FAA?

  What actions, if any, did you take to notify the principal inspector (PI)?

  Is any CA PTRS reference in the appropriate format?

  See additional documentation details in paragraph 14-1-2-9.

Upload and refer to supporting records, pictures, certificates, statements, emails, and letters.

Create appropriate CA PTRS records for regulatory or statutory deviations by the airmen or individuals involved.

1.3

Select all “Response Details” that apply.

Explain “Other” choice in “Supporting Comments.”

10-5-2-9A

1.4

Document additional details in the “Supporting Comments” field:

Explanations must be complete and descriptive so that anyone knowledgeable within the industry can understand the response without requiring additional information.

Refer to any uploaded documents when explaining your actions. You may refer within “Supporting Comments” to an uploaded attachment that contains the RCA. This technique is useful to support several related unfavorable answers.

Explain the reason if you select the “PI Alert.”

Explain an “Other” Response Detail choice in “Supporting Comments.”

Include references to related personnel CA PTRS records.

10-5-2-9A

Table 10-5-2C

14-1-2-7

14-1-2-9G

14-1-2-9H

 

  What specific (guidance, safety, manual, regulatory, or statutory) requirement was not met?

  When did it occur?

  Where did it occur?

In addition, include the following if known prior to closing the DCT to support managing the CA in Analysis, Assessment, and Action (AAA):

  What are the results of the Root Cause Analysis (RCA)? (Why did it occur? What caused the error?)

  What were the identified hazards or ineffective risk controls? (Include behaviors that led to the problem.)

  How was the problem corrected? (Document mitigations/corrective actions taken by the certificate holder.)

  Document coordination with the PI/CHDO for complex or long-term followup.

  Is any CA PTRS reference in the appropriate format?

  See additional documentation details in paragraph 14-1-2-9.

1.5

DCT is complete, accurate (per the DQG), and submitted within 5 business-days, by the due date, or per PI instructions.

10-5-2-9D

Table 10-5-3A

 

  Comments must include a description of the problem and what actions were taken.

  Comments and information should (if known at the time) answer the “Who, What, When, Where, and Why.

  Comments must document any immediate corrective action taken by the certificate holder showing the noncompliance ceased.

  Some requirements may not be met in Module 4 and must wait until the PI performs additional analysis in Module 5.

It is very important for data collectors to document their communication and coordination with the PI on followup within the DCT so reviewers understand the requirements that will be tracked and accomplished later. Documenting the coordination makes both the data review process and any required followup more efficient and effective. It is equally important for reviewers to use critical thinking to determine what documentation is appropriate to the facts and circumstances known during the data collection. It is expected that personnel will work interdependently with each other and FLMs when questions arise about the amount or level of documentation for a CA in Module 4.

 

SAS Module 5 Compliance Action (CA) Documentation Review Job Aid

2.0

Principal Inspector (PI) Analysis, Assessment, and Action (AAA):

Reference

2.1

ANALYZE: Review the DCT documented facts, actions, and behaviors. Consider the recorded history of compliance.

10-6-1-9

14-1-2-7

 

Are there data quality issues?

If yes, Return DCT with explanation.

 

Is there enough data to make an assessment?

If no, ADD a DCT to the CAP or Return with instructions

2.2

ASSESSMENT: 1G “No issues or findings” is a validation of the system. Do not make an assessment statement, do not select action, and do not make an action statement. You may communicate no issues or findings with the certificate holder, but do not select “NOTIFY CERTIFICATE HOLDER.” You may upload a letter or record of conversation.

10-6-1-9

14-1-2-7

14-1-2-9

 

ASSESSMENTS 2Y “Minor nonregulatory,” 3Y “Regulatory nonsystemic,” or 4R “Regulatory and/or Systemic” require: “ACTION;” “ASSESSMENT DETERMINATION JUSTIFICATION;” and “ACTION JUSTIFICATION.”

2.3

ACTION: After a full assessment, the PI chooses the appropriate action to document that no followup is required, to gather more data, or to mitigate the risks that led to the issues. The PI may add actions and/or initiate nonregulatory CA for hazards, safety concerns, or recommendations, or when additional followup is necessary. This will be tracked on the AITT. Justification must be provided in the AITT to close the item.

10-6-2-9

14-1-2-7

14-1-2-9

 

NOTIFICATION TO CERTIFICATE HOLDER: For letters outlining assessment results or findings, see Volume 1, Chapter 3, Section 1 and Volume 14, Chapter 1, Appendix 14-3, Compliance Action Communication/Correspondence Guidelines.

1-3-1

Appendix 14-3

 

3Y Assessments: When the PI determines the risk of reoccurrence is fully addressed and mitigated at the point of discovery, a “REGULATORY COMPLIANCE ACTION” choice must be selected.

10-6-2

Table 10-6-2A

14-1-1-7E

14-1-2-7

14-1-2-9

 

3Y or 4R Assessments requiring further action for regulatory issues must have a “REGULATORY COMPLIANCE ACTION” or “INITIATE ENFORCEMENT choice selected.

 

4R Assessments for nonregulatory systemic issues must not have a “REGULATORY COMPLIANCE ACTION” or “INITIATE ENFORCEMENT choice selected.

 

“INITIATE ENFORCEMENT” is required when: the certificate holder is unwilling or unable to comply; a pattern of poor performance is shown; there is a failure to implement agreed upon corrective action(s); or when required by law. Review additional criteria in paragraph 14-1-1-7E.

2.4

Review justification statements to ensure they align and support assessment and action choices

 

“Assessment Determination Justification”

“Action Justification”

 

Identify the issue, state the root cause(s) including behaviors, and identify any noncompliance or systemic issues. Close with:

  The risk was fully mitigated at the point of discovery;

  More data needed to ensure risk is mitigated; or

  Underlying issue(s) warrant(s) further correction.

  Notification to the certificate holder explaining issues.

  No further action required.

  Follow up to ensure the risk is fully mitigated.

  Actions needed to examine possible systemic issues.

  The behavior/performance requires enforcement.

2.5

Manage CA: The PI must document the results of the Root Cause Analysis (RCA), the identified hazards or ineffective risk controls, and how the problem was corrected.

10-6-2-9

14-1-2-9

 

 

PTRS Compliance Action (CA) Documentation Review Job Aid

Reference

1.0

Comments must include a documentation of the facts. Documentation must be clear and stand alone in later history searches, showing the noncompliance stopped and that any fixes put in place to prevent recurrence were effective.

14-1-2-9J

1.1

Who was involved with the deviation?

14-1-2-7B, 14-1-2-9F1)

1.2

What specific regulatory or statutory requirement was not met?

14-1-2-9F4)

1.3

When did the deviation occur?

14-1-2-9F4)

1.4

Where did the deviation occur?

14-1-2-9F4)

1.5

Why did the deviation occur? What are the results of the Root Cause Analysis (RCA)? What were the identified hazards or ineffective risk controls, including behaviors, that led to the deviation?

14-1-2-7B, 14-1-2-9F4)

1.6

What was done to communicate or transfer any nonregulatory concerns or potential risks?

14-1-2-7A1), C1)

2.0

Document FAA action and mitigations/corrective actions taken by the airman/organization.

 

2.1

Does the PTRS capture the controls, monitoring, and feedback required to mitigate risks and ensure compliance?

14-1-2-7D, 14-1-2-9F4)

2.2

What were the mitigations/corrective actions taken by the airman/organization and the FAA?

14-1-2-7C, 14-1-2-9F4)

2.3

How was the problem corrected?

14-1-2-7D, 14-1-2-9F4)

2.4

Is there sufficient information for future review of what the problem was and how it was fixed?

14-1-2-9F4)

3.0

Record of deviation in PTRS and Multiple Records Requirement.

 

3.1

If possible, was a CA PTRS triggered from the primary PTRS surveillance activity? If so, was the triggered record entered in the parent PTRS?

14-1-2-9D

3.2

Was the appropriate CA PTRS activity code (*7** for investigating ASIs or *9** for FAA Safety Team (FAASTeam)) selected for the compliance action and any triggered followup surveillance? Note the followup surveillance should not be documented with an additional CA PTRS but rather with a surveillance (*6**) or other appropriate PTRS activity code.

14-1-2-9E

3.3

Linking triggered records: Within the parent activity PTRS, was a keyword “907” and opinion code “I” comment entered containing the triggered PTRS transmittal ID?

14-1-2-9D

3.4

Are nonregulatory concern comments coded separately with keyword “911” and opinion code “I”?

14-1-2-9B

3.5

Is the date of occurrence entered in the comments if different from the start date?

PPM, page 4-7, Start Date

4.0

Additional Training and Remedial Training (RT).

 

4.1

Was the airman’s agreement to participate in RT documented in the Additional Training PTRS?

14-1-2-9F4)h), 14-3-2-9A

4.2

Was the parent PTRS transmittal ID provided to the FAASTeam Program Manager (FPM) and entered in the RT PTRS with keyword “907” and opinion code “I”?

14-3-2-9A

4.3

Was the RT PTRS triggered from the parent PTRS or the transmittal ID provided to the referring ASI and entered in the Additional Training PTRS record with keyword “907” and opinion code “I”?

14-1-2-9F4)h), 14-3-2-9A

4.4

Was the Additional Training CA PTRS kept open until the RT was completed?

14-1-2-9F4)h), 14-3-2-9A

5.0

Trigger followup surveillance activities (only when needed).

 

5.1

Did the airman/organization complete all corrective action(s) satisfactorily?

14-1-2-7E, 14-1-2-9H

5.2

If the entity failed to complete an agreed-upon action, were the CA PTRS comments annotated, the CA PTRS terminated, and an Enforcement Action PTRS triggered?

14-1-2-9I

5.3

If agreed-upon corrective actions failed to achieve their intended purpose, were additional corrective actions documented in the PTRS comments?

14-1-2-9H

5.4

When necessary, has the PTRS documented any followup inspection and been closed after confirming compliance?

14-1-2-9H