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8900.1 CHG 422

VOLUME 14  COMPLIANCE AND ENFORCEMENT

CHAPTER 1  flight standards service COMPLIANCE policy

Section 1  Flight Standards Service Compliance Philosophy

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14-1-1-1    GENERAL. In 2015, Federal Aviation Administration (FAA) Order 8000.373, Federal Aviation Administration Compliance Philosophy, was published, followed by Notice 8900.323, Flight Standards Service Compliance Policy. New Volume 14, Chapter 1, Sections 1 and 2, were published to align AFS policy with Order 8000.373, N 8900.323, and related changes to the current edition of FAA Order 2150.3, FAA Compliance and Enforcement Program1. Together, these changes enabled FAA program offices such as AFS to become policy owners for Compliance Actions below the level of administrative or legal enforcement action. See Volume 14, Chapter 1, Section 2, subparagraph 14-1-2-3D for the definition of Compliance Action. On February 2, 2016, N 8900.343, Flight Standards Service Compliance Policy, replaced N 8900.323. Volume 14 changes are incorporated as described in the new notice and also in response to Compliance Philosophy (CP) feedback received from internal and external stakeholders. N 8900.343 content remains in effect until incorporated in this order.

A.    Purpose. This section provides the basis for and outlines the AFS CP. This section introduces the use of AFS Compliance Action to address, when appropriate, safety concerns and actual or apparent deviations from regulations or standards discovered during inspections or surveillance. AFS CP directly supports the FAA CP, conserving FAA resources by using the most efficient and effective means to return an individual or entity to full compliance and to prevent recurrence.

B.    Scope. The AFS CP should be routinely applied to all AFS interactions with airmen, certificated entities, non-certificated persons, and to all AFS investigatory processes, using the procedural guidance in Volume 14, Chapter 1, Section 2. Except as described in the FAA CP, or as required by law and specific program commitments, where older AFS policy conflicts with Volume 14, Chapter 1, Sections 1 and 2, this newer policy must be followed until the older policy is revised. The AFS Director is committed to reviewing all prior program commitments (see note below) and revising them, where appropriate, to align with the FAA CP. When in doubt as to the appropriate course of action or policy to follow, inspectors should work through their Front Line Managers (FLM) and office managers with the appropriate regional branches and policy divisions for clarification.

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NOTE:  AFS must follow policy and process commitments made to Congress, the Inspector General (IG), and other external parties. Inspectors must be mindful of these commitments and respect other critical processes outlined in FAA policy. Examples include, but are not limited to, Airworthiness Directives (AD)2, Aviation Safety Action Programs (ASAP)3, Aviation Safety Reporting Program (ASRP)4, flight operations quality assurance (FOQA)5, all noncompliance by military and foreign pilots6, Special Emphasis Enforcement Programs7, and Voluntary Disclosure Reporting Programs (VDRP)8. As time permits, AFS will review and revise these commitments as necessary to align them with the FAA CP and AFS Compliance Policy. See paragraphs 14-1-2-7 and 14-1-2-9 for additional ASAP and VDRP requirements.

14-1-1-3    BACKGROUND.

A.    FAA Statutory Authority. The FAA’s statutory authority to prescribe, revise, and enforce standards is in Title 49 of the United States Code (49 U.S.C.), Subtitle VII, chapter 447, Safety Regulation, and is the foundation for the purpose and mission of AFS.

B.    Shared Safety Duties and Responsibilities. The responsibility for aviation safety does not rest entirely with the FAA. All airmen, air carriers, aircraft owners and operators, air agencies, and certain airport operators who qualify for and accept an FAA certificate have statutory or regulatory safety duties. The safety of our National Airspace System (NAS) is based on each individual certificate holder’s duty and responsibility to provide for public safety and for air carriers to provide service with the highest possible degree of safety in the public interest9. Aviation service providers must provide their services or products in a manner that is compliant with regulations and standards, and they must do so safely.

C.    Historical Compliance and Enforcement Program Supports the FAA CP. Public law and agency policy allow FAA program offices to use discretion when taking action to resolve safety issues in the NAS. For several years, the FAA Compliance and Enforcement Program (Order 2150.3, Chapter 2) has included the following policy language:

1)    Voluntary Compliance. “Civil aviation safety depends on voluntary adherence to legal requirements. Therefore, the FAA administers programs to promote a clear awareness and understanding of the governing statute and regulations.”
2)    Education. “FAA investigative personnel should take advantage of opportunities during their surveillance and inspection activities to strengthen a regulated person’s understanding of the statutory and regulatory requirements. The FAA also promotes education through public awareness programs and other special aviation educational efforts.”
3)    FAA Responses to Noncompliance. “[P]ersonnel must…appropriately address every apparent or alleged violation.… The agency has a wide range of options available for addressing apparent [noncompliance found during inspections and surveillance].”
4)    Recommendations. “FAA investigative personnel… [o]ften… are in the best position to evaluate various subjective considerations… and whether an alternative to legal enforcement action may be sufficient to achieve compliance.”

D.    Regulatory Goals. The ultimate goal is to prevent deviation from regulatory standards, a goal primarily achieved through design and application of effective processes and practices; education and counseling designed to encourage awareness and understanding of risks; and voluntary compliance. All inspectors must become involved in this evaluation, education, and counseling process.

E.    Voluntary Compliance and Collaboration. The high level of safety in the NAS is largely based on, and dependent upon, voluntary compliance with regulatory standards. Our safety record shows that the majority of NAS participants have a good safety culture. The success of FAA voluntary programs such as the ASAP and VDRP has demonstrated that a collaborative CP, supported by a positive safety culture, provides the highest levels of compliance with regulations, the most effective identification of hazards, and the most efficient management of risks.

14-1-1-5    EVOLUTION OF COMPLIANCE STRATEGIES.

A.    The 2014 FAA Strategic Initiatives10:

1)    Global Leadership. To improve safety, air traffic efficiency, and environmental sustainability across the globe through an integrated, data-driven approach that shapes global standards enhances collaboration and harmonization, and better targets FAA resources and efforts.
2)    NAS. Lay the foundation for the NAS of the future by achieving prioritized Next Generation Air Transportation System (NextGen) benefits, integrating new user entrants, and delivering more efficient streamlined services.
3)    Risk-Based Decision Making. Build on system management principles to proactively address emerging safety risk by using consistent, data-informed approaches to make smarter, system level, risk-based decisions.
4)    Workforce of the Future. Prepare FAA’s human capital for the future by identifying, recruiting, and training a workforce with the leadership, technical, and foundational skills to ensure the United States has the world’s safest and most productive aviation sector.

B.    Increasing NAS Complexity. Traditional oversight relies on the assumption that if an airman/organization is fully compliant with the applicable regulatory requirements, then an adequate level of safety is achieved. However, the aviation environment has reached a level of complexity where further safety improvements cannot be achieved by simple compliance with prescriptive rules.

C.    Compliance Strategy Evolution. The FAA’s Strategic Initiatives, increasing NAS complexity, and unknown emerging hazards/risks require AFS compliance strategies to evolve. The AFS workforce must exercise interdependence, critical thinking, and consistency while working together with all NAS users to achieve a higher level of compliance and safety11. Regulatory compliance must move beyond viewing the regulations simply as administrative or legal requirements; compliance entails effective control of clearly defined hazards, as intended in the rules.

14-1-1-7    COMPLIANCE PHILOSOPHY.

A.    Greatest Safety Risk. The outcome of an event is not what determines whether or not the behavior is acceptable or unacceptable. The greatest systemic safety risk is not from a specific operational event or its outcome, but rather from an airman or organization’s unwillingness or inability to comply with safety standards and, most importantly, operating contrary to the core principles of Safety Risk Management (SRM). AFS must be more efficient and effective in resolving deviations and must use the strongest responses for airmen/entities whose behaviors represent the greatest safety risk to the NAS.

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B.    Goal. The goal is to identify safety issues that underlie deviations from standards and correct them as effectively, quickly, and efficiently as possible. Inspectors should use the most effective means to return an individual or entity that holds an FAA certificate, approval, authorization, or license to full compliance and to prevent recurrence. The AFS CP requires AFS personnel to engage in a solution-oriented, outcomes-based approach to identify safety issues and correct noncompliance. Inspectors are expected to use interdependence and critical thinking to evaluate the discrete facts of a particular situation, and then choose the best tool to fix the problem, consistent with regulations, policies, and the specific circumstances of each event. Followup is used to validate that the desired corrective actions were taken, and that they had the intended outcome for safety and compliance. This view of compliance stresses a problem-solving approach where enhancement of the safety performance of individuals and entities is the goal. This approach will more effectively address inadvertent deviations and conserve FAA enforcement resources for intentional, reckless12, criminal, and uncooperative behavior. If the deviation does not involve intentional, reckless, or criminal behavior and the airman/organization is qualified and willing to cooperate, AFS should resolve the issue through use of compliance tools, techniques, concepts, and programs.

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C.    Most Deviations Can Be Effectively Corrected. Deviations by certificate holders often arise from factors such as flawed procedures, simple mistakes, lack of understanding, or diminished skills. The FAA believes that deviations of this nature can most effectively be corrected through Root Cause Analysis (RCA)13 and appropriate corrective actions by the airmen/entities involved, which are documented and verified by AFS to ensure effectiveness. Inspectors must contemplate all the tools available and apply the remedy most appropriate to the specific circumstances. Possible remedies to address deviations include, but are not limited to: training/education, on-the-spot corrections, counseling, and remedial training. Improvements to systems, procedures, or training programs for organizations may also be appropriate. The inspector documents corrective actions taken by the airman/organization and verifies the actions were effective through appropriate followup.

D.    Effective Problem-Solving. The focus of the AFS workforce should be to collaborate with the parties involved on correctly identifying and fixing the root cause(s) of deviations or noncompliance.

1)    Fixing root causes is the best way to prevent recurrence. In the majority of cases, finding and fixing safety problems in all parts of the NAS can be done most effectively with a collaborative approach and the voluntary participation of all parties involved. AFS inspectors and other staff can have a significant impact on safety by remaining focused on problem-solving, correctly identifying root causes, and recommending appropriate corrective actions to adequately mitigate the risks involved. Such a focused and unbiased approach will normally be a strong encouragement to collaboration and voluntary compliance from those involved.
2)    Inspectors must use critical thinking in a problem-solving approach that stresses developing effective individual and organizational risk management (RM) environments. When appropriate, inspectors should engage collaboratively with airmen and organizations to encourage development of system-level risk mitigations on issues for which such methods may effectively ensure ongoing compliance.

E.    Use of Enforcement and Other Tools/Resources When Needed.

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1)    The FAA views intentional or reckless deviations from regulatory standards (as described in Volume 14, Chapter 3, Section 5 and Order 2150.3, chapter 5) or patterns of behavior or performance that present an unacceptable risk to safety as posing the highest risk to safe operation of the NAS. Those deviations require strong enforcement14.
2)    Failure to implement or to complete corrective action on terms satisfactory to the FAA.

NOTE:  A failure to implement agreed-upon corrective action differs from implementing an agreed-upon corrective action that does not achieve its intended purpose. In the latter case, further Compliance Action for additional/revised corrective action(s) may be appropriate.

3)    Conduct that creates or threatens to create a significant risk to safety when the Flight Standards Service Director (AFS-1) determines that alternative means to address the noncompliance and to effectuate immediate and future compliance would not be sufficient. These instances are normally initiated by the Director.
4)    Legal enforcement action will be taken when required by law (the express terms of a statute or regulation).
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5)    Matters involving qualifications or competence of certificate holders will be addressed appropriately by following FAA policy on retraining, reexamination, and/or enforcement. (Refer to Volume 14, Chapter 3, Section 2; Volume 5, Chapter 7; and Order 2150.3, chapter 5, paragraph 8.)
6)    Regulatory violations involving criminal activity will be referred to FAA Security for coordination with the proper Law Enforcement Organization and may be addressed by AFS personnel with enforcement. (Refer to Order 2150.3, chapter 5, paragraph 9.)

14-1-1-9    AFS COMPLIANCE EXPECTATIONS FOR NAS USERS.

A.    Regulatory Risk Controls. The FAA establishes regulatory standards to ensure safe operations in the NAS. When an airman’s behavior or performance, or an organizational system’s behavior or performance, presents an unacceptable risk, the FAA may propose new risk controls, which are established through a public process as regulations. Therefore, behaviors or performance contrary to a regulatory standard represents a previously identified unacceptable risk.

B.    Managing Operational Risks.

1)    Regardless of how robust and compliant a system is, risk still exists; developing rules for every possible situation is ineffective, if not impossible. Although compliance is still a minimum expectation, experience has shown that simple compliance with regulations does not guarantee safety. Operational risks must still be managed through positive system-level action by the airmen and organizations themselves. It is important to recognize that this obligation includes a duty to develop and use processes and procedures that will prevent deviation from standards and enhance safety.
2)    In some situations based on unique equipment, conditions, experience, training, or type of operation, even behaviors or performance within regulatory standards may present unacceptable risk. In those cases, the FAA expects individuals or entities to proactively identify and manage those risks. For example, in private, personal, or recreational aviation, the FAA promotes the best practice of pilots setting their own personal weather minimums to manage individual safety risks. In commercial aviation, the FAA expects organizations to manage their unique risks through specialized training or with procedural tools like formal hazard identification and risk assessments. In short, every participant in the NAS has a duty to manage the safety risks unique to that participant, with those risks mitigated to a level appropriate to the public interest involved.

C.    Safety Management Systems (SMS). SMS has been adopted worldwide as a management tool and standardized approach to managing risk. The goal is to ensure that all potential associated hazards are identified and analyzed, and that the risk is either accepted or mitigated to an acceptable level through controls.

1)    In the Title 14 of the Code of Federal Regulations (14 CFR) part 121 air carrier environment, the FAA now requires the use of SMS. Title 14 CFR part 5 specifies a basic set of processes integral to an effective SMS but does not specify particular methods for implementing these processes. The FAA expects each air carrier to develop an SMS that works for its unique operation.
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2)    To reach the highest level of safety and compliance with regulatory standards, the FAA is implementing SMS constructs as a best practice throughout the NAS based on comprehensive safety data sharing between the FAA and the aviation community. In essence, the FAA will be evaluating other organizations’ SRM processes to see how well they each provide methods that identify the hazards and control the risks they have identified. Safety data shared by NAS participants through voluntary safety programs such as company internal hazard reporting, ASAP, Aviation Safety Reporting System (ASRS), VDRP, and others have contributed significantly to FAA and industry knowledge of risks in the NAS. These data collection and sharing programs should be encouraged and expanded to mitigate such risks before they lead to mishaps. At the individual airman level, the same safety benefits can be realized using the CP with open conversations and collaborative problem solving to properly identify root causes and permanently fix safety issues.
3)    The SMS approach is applicable to individual airmen as well as to large and complex organizations. It offers a problem-solving approach where individuals and organizations have the primary responsibility for safety performance enhancements. Good safety management practices are expected of all airmen and organizations.

D.    Human Factors and Human Error.

1)    Human beings commit errors. Even the most dedicated professionals can inadvertently drift from full compliance with policies, processes, and procedures due to complacency or shortcomings in the larger systems in which they work. Unfortunately, the complexity of today’s aerospace system means that even inadvertent and unintentional errors (honest mistakes) can have a serious adverse impact on safety.
2)    To address the risk of human error, an airman or organization must account for the inevitability of human error through effective safety barriers and risk controls that focus on prevention, detection, and the mitigation of error consequences on the NAS. Deviations must be identified and resolved by airmen/organizations, collaborative/voluntary programs, or by AFS surveillance and followup. In addition, there must be expectation of, and appreciation for, self-disclosure.
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14-1-1-11    COMPLIANCE EXPECTATIONS FOR AFS EMPLOYEES.

A.    Policy. Inspectors will follow the Compliance Action Decision Process in Volume 14, Chapter 1, Section 2. Compliance Action Program Tracking and Reporting Subsystem (PTRS) records must hold up under internal and external review.

B.    Professionalism. The FAA must demonstrate a high level of professionalism and cooperation while engaged in Compliance Action. Each inspector’s acts, communication, and behavior should reduce the fear of unreasonable FAA actions and nurture or reinforce effective safety reporting from airmen/organizations.

C.    Active Communication. Inspectors will communicate with the parties involved in an apparent deviation or noncompliance and seek agreement on a corrective action plan (CAP) which adequately addresses the root cause(s) that led to the noncompliance. Airmen/organizations should be given a reasonable time to implement corrections, with a clear suspense date and expectation of followup from AFS. The agreed-upon corrections will be implemented and monitored to ensure future compliance. If the corrective measures are later determined to be inadequate, inspectors will continue to communicate with the airmen/organizations to adequately mitigate remaining risks.

D.    Foundational Expectations15. Inspectors will use interdependence and critical thinking to evaluate the discrete facts of a particular situation and then choose the best tool(s) to fix the problem, ensuring the outcome is consistent with regulations, policies, and the specific circumstances of each event.

E.    Just Culture16. AFS must be fair, reasonable, and just. Inspectors must consider all circumstances relating to the facts and allegations. They must make a good faith effort to understand the position of the airman/organization and to communicate the agency’s position in a timely manner. AFS must promote and implement a just safety culture approach. Errors must be identified, reported, and analyzed in a non-blaming manner so that appropriate remedial or system-wide corrective action can be taken based on the specific facts and circumstances of each case. Inspectors must understand the difference between accountability, which accepts responsibility and looks forward, and blame, which focuses on punishment for what has already occurred. Key to a just safety culture is the ability to determine where the line should be drawn between blameless unsafe acts that can be effectively addressed through use of compliance tools and unacceptable behavior that requires use of enforcement action.

F.    Consistent Application. To be effective, the AFS CP must be applied consistently across AFS.

1)    Every situation is different. Inspectors must recognize there are many ways for regulated entities to comply with regulations and operate safely. The consistent result should always be effectively managed risk. In this context, consistency means interdependently evaluating each discrete set of facts and anchoring our work in rules and standards, consistent with rule and policy interpretations, and ensuring that safety risks are effectively managed.
2)    Compliance Action may be utilized when a deviation from standards arises with an airman/organization and the inspector can reasonably be assured that future compliance can be achieved through the action. The decision to use Compliance Action may be made by the inspector during the course of observation, surveillance, inspection, investigation, etc.
3)    Inspectors must emphasize to each airman/organization that it is their responsibility to develop and take corrective actions to remain in compliance. When in doubt as to the effectiveness or appropriateness of any airman/organization corrective actions, inspectors must work interdependently with colleagues to determine whether, and how, the airmen/organization can mitigate risk to the extent needed to meet their current and future compliance obligations. In other words, make sure the problem is fixed.

G.    Due Process Considerations. The below explanations and example scenario are provided to illustrate the interrelationship between Compliance Actions, Enforcement Actions, and the Pilot’s Bill of Rights (PBR) notification requirements. The scenario is not intended to represent the workflow or process used to address a pilot deviation (PD). Regardless of any Enforcement Action taken, the primary focus of the inspector in every case should be stopping any noncompliance and mitigating any safety risks in the NAS. Safety mitigation steps have been left out of the below paragraphs for clarity of the due process illustration.

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NOTE:  In PTRS records and in communications with the certificate holder, clearly identify the findings and required actions that have a regulatory basis and any other non-regulatory FAA concerns/recommendations to make improvements or use best practices. Document these non‑regulatory recommendations per Volume 14, Chapter 1, Section 2, subparagraph 14-1-2-9B).

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1)    Compliance Action. When an inspector discovers safety concerns or an apparent or actual deviation from standards, ensures the deviation has stopped, and concludes that Compliance Action is appropriate (using the Compliance Action Decision Process in Volume 14, Chapter 1, Section 2), successful completion of the FAA’s Compliance Action documentation (in the PTRS and/or SAS) may be all that is necessary to close the issue.
a)    The CP supports open and transparent safety information sharing between the FAA and airmen/organizations. Compliance Action is a method to correct unintentional deviations or noncompliance that arise from factors such as flawed procedures, simple mistakes, lack of understanding, or diminished skills. Its only purpose is to restore compliance and to identify and correct any underlying cause(s) that led to the deviation.
b)    Aviation safety inspectors (ASI) must consider restoring compliance and mitigating the safety risk as the overall purpose of any inquiry involving a potential noncompliance. Although the investigation may reveal that action needs to be taken with an airman, addressing the overall safety issue remains the target of the investigation.
2)    CP and the PBR. A Brochure has been developed with information on the CP that also includes content meeting the PBR Act notification requirements.
a)    The Brochure is available in this volume’s Appendix 14-1, Compliance Philosophy and Pilot’s Bill of Rights Brochure, and at www.faa.gov/go/cp. All ASIs areencouraged to provide the brochure at public aviation events, and through any other opportunity to share safety or policy information.
b)    See Volume 14, Chapter 1, Section 3 for new PBR policy and required uses of the Brochure for investigatory and other airman contacts.
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3)    Reconsideration After Starting Compliance Action. If an initial attempt is made at Compliance Action, but facts and circumstances later indicate that enforcement action is required, a Letter of Investigation (LOI) should be sent, including PBR notification for airmen. An LOI is not required if an airman has already provided adequate input to determine that Administrative Enforcement Action is appropriate, in which case a Streamlined Administrative Action, Warning Notice, or Letter of Correction can be sent without an LOI. PBR notification must still be provided to airmen by the ASI for locally generated Administrative Actions. Even if a Compliance Action PTRS record is terminated and Enforcement Action is taken, AFS personnel must remain focused on resolving the safety issues at hand, which could include ongoing communication with the airman/organization to stop any noncompliance, mitigate risk, and prevent recurrence.
4)    Administrative Enforcement Action. Sufficient evidence must exist to prove an apparent deviation or noncompliance in order to take Administrative Action, but that evidence need not meet the same standards required for Legal Enforcement Action.
a)    For example, AFS receives notification from the Air Traffic Organization (ATO) of a suspected PD, and ATO automatically retains some data on the event in the Knowledge Services Network (KSN) system. The inspector assigned to review the suspected PD can print, save, and review this data and make a determination that Compliance Action is appropriate.
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b)    If the involved airman/organization’s performance or behavior becomes unacceptable as described above in subparagraph 14-1-1-7E1), or the agreed-upon corrective action is not implemented, a Warning Notice may be appropriate if the saved KSN data substantiates noncompliance. For the newly unacceptable compliance performance/behavior, inspectors are encouraged to continue communicating with the airman/organization through an LOI, including clarifying that Enforcement Action is now the minimum FAA response based on the unacceptable behavior or insufficient corrective action.
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c)    An LOI (with PBR notification for airmen) is normally required when, despite the inspector’s reasonable efforts to communicate and restore compliance, the airman/organization’s behavior or performance is unacceptable per subparagraph 14-1-1-7E1) and the inspector has (or believes he or she can obtain) sufficient evidence to legally prove all elements of an apparent violation. An LOI is not required if an airman has already provided adequate input to determine that Administrative Enforcement Action is appropriate, in which case a Streamlined Administrative Action, Warning Notice, or Letter of Correction can be sent without an LOI. PBR notification must still be provided to airmen by the ASI for locally generated Administrative Actions.
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5)    Legal Enforcement Action. Our first priority is always to solve the safety problem. It is important to solve the majority of safety problems at the appropriate level through Compliance Action whenever possible, which supports and improves the already good safety culture in the NAS. As a matter of policy, AFS accepts the fact that we may sometimes lose the opportunity to take Legal Action because the opportunity to collect perishable evidence was missed. Completed and terminated Compliance Actions, and Administrative Actions, are still documented with PTRS records, which can be used to establish a pattern of behavior in the future. An LOI (with PBR notification for airmen) is required when, despite the inspector’s reasonable efforts to communicate and restore compliance, the airman/organization’s behavior or performance is unacceptable per subparagraph 14-1-1-7E1), or when Legal Enforcement Action is otherwise required by law or policy.

NOTE:  Airman statements are not the only evidence available to support Legal Action. For example, if a mechanic admits (before receiving PBR notification) to deliberately installing an incorrect part because the correct one wasn’t available, the installed part and the approval for return to service logbook entry are sufficient evidence to move forward with a 14 CFR part 43, § 43.13(a) case even though the admission may not be used to cite § 43.12(a)(1).

6)    Reconsideration After Starting Enforcement Action. See Volume 14, Appendix 14-5, Guidance for Review of Enforcement Cases Under the FAA’s Compliance Philosophy, for work instructions on AFS or FAA Office of the Chief Counsel (AGC) changing FAA’s response after an Enforcement Information System (EIS) entry has been made. These instructions were developed in coordination with AGC.

H.    Safety Management and Data Quality. Internal to the FAA, quality documentation of safety issues within AFS data systems is essential to provide useful historical information and data for systemic analysis. AFS personnel must keep safety management principles in mind when recording deviations (e.g., in the comments section of the PTRS or other data systems). Detailed reporting allows for a more complete map of risk factors and risk behaviors for analysis. The more we can learn about precursor risk factors, the greater the opportunity to drive down accident probabilities even further. A single event may seem minor, but multiple events may indicate increased risk. Habitually recording these minor events enables larger problems to be identified.

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I.    Consider All Compliance Tools. AFS is confident that inspectors (following Compliance Action policy guidance, working interdependently, and using critical thinking) will correctly identify events, consider all the compliance tools available17, and apply the remedy most appropriate to the specific facts and circumstances.

14-1-1-13    REFERENCES.

A.    Additional Policy Guidance (current editions):

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·    FAA Notice 8900.343, Flight Standards Service Compliance Policy (replacing N 8900.323).

·    FAA Order 8000.373, Federal Aviation Administration Compliance Philosophy.

·    FAA Order 2150.3, FAA Compliance and Enforcement Program.

·    FAA Order VS 8000.367, Aviation Safety (AVS) Safety Management System Requirements.

·    FAA Order 8000.368, Flight Standards Service Oversight.

·    FAA Order 8000.369, Safety Management System.

·    FAA Order VS 8000.370, Aviation Safety (AVS) Safety Policy.

·    FAA Order 8000.88, PRIA Guidance for FAA Inspectors.

·    FAA Order 8040.4, Safety Risk Management Policy.

·    FAA PTRS Procedures Manual (PPM) (which includes information on releasability under the Freedom of Information Action (FOIA)): http://fsims.faa.gov/wdocs/other/ptrs_procedures_manual.htm.

·    FOIA Exemptions Summary Sheet: https://my.faa.gov/content/dam/myfaa/org/staffoffices/afn/administration/foia/foia_tool_kit/worktools/FOIA-Exemptions-Summary.pdf.

B.    Handbooks and Advisory Circulars (AC) (current editions):

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·    FAA-H-8083-2, Risk Management Handbook: http://www.faa.gov/regulations_policies/handbooks_manuals/aviation/media/risk_management_hb_change_1.pdf.

·    AC 120-92, Safety Management Systems for Aviation Service Providers.

C.    Other Information:

·    Global Aviation Information Network (GAIN), A Roadmap to a Just Culture, First Edition, September 2004, available at http://flightsafety.org/files/just_culture.pdf.

·    Eurocontrol, Just Culture Web page at http://www.skybrary.aero/index.php/Just_Culture.

·    Sidney Dekker, Just Culture: Balancing Safety and Accountability, Second Edition, 2012.

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·    Sidney Dekker, Second Victim: Error, Guilt, Trauma, and Resilience, 2013.

·    Sidney Dekker, The Field Guide to Understanding ‘Human Error,’ Third Edition, 2014.

·    R. Key Dismukes, Benjamin A. Berman, and Loukia D. Loukopoulos, The Limits of Expertise: Rethinking Pilot Error and the Causes of Airline Accidents, 2007.

·    ‪James Reason, Managing the Risks of Organizational Accidents, 1997.

·    Report of the Independent Review Team, Managing Risks in Civil Aviation: A Review of the FAA’s Approach to Safety, 2008, at http://www.faa.gov/aircraft/air_cert/continued_operation/ad/ad_arc/media/IRTreport.pdf.

·    Malcolm K. Sparrow, The Regulatory Craft: Controlling Risks, Solving Problems, and Managing Compliance, 2000, at https://openlibrary.org/books/OL8050332M/The_Regulatory_Craft.

·    Aviation Risk Management Solutions (ARMS) Working Group, The ARMS Methodology for Operational Risk Assessment in Aviation Organisations, 2010, at http://www.skybrary.aero/bookshelf/books/1141.pdf.

·    Eurocontrol, Systems Thinking for Safety: Ten Principles (A White Paper), 2014, at http://www.skybrary.aero/index.php/Toolkit:Systems_Thinking_for_Safety:_Ten_Principles.

D.    Training Resources.

1)    Root Cause Analysis (RCA) Introduction (Course FAA27000008). A 60-minute online course, the Introduction to Root Cause Analysis (RCA) course goal is for the workforce to gain an appreciation of RCA through an introduction of concepts, tools, and illustrative examples.
2)    Root Cause Analysis Overview (Briefing FAA30120001). A 2-hour online briefing, including:

·    RCA terms and definitions;

·    Corrective and preventive action;

·    Methods used to determine root causes;

·    Techniques used for three RCA methods;

·    Five whys; and

·    Fishbone method examples.

3)    Root Cause Analysis Workshop (Workshop FAA30120002). A 4-hour instructor-led workshop, including:

·    RCA tools;

·    Cause and effect diagrams;

·    Fault trees;

·    Five whys;

·    Cause and effect analysis;

·    Problem statement construction;

·    Data collection; and

·    Developing corrective and preventive actions.

4)    Root Cause Analysis for Quality Management (Course FAA24914). An 8-hour instructor-led course offered Aviation Safety (AVS)-wide, the course material directly supports the Quality Management System (QMS) and indirectly supports other investigation activities.

14-1-1-15    FUTURE TASKS. See Volume 14, Chapter 1, Section 2, Flight Standards Service Compliance Action Decision Procedure.

14-1-1-17 through 14-1-1-31 RESERVED.



1 With AFS-1 Priority Project publication of this new Chapter 1: former (“legacy”) Volume 14, Chapter 1, Sections 2 through 7 were updated and moved to Chapter 2 and 3; former Chapter 1, Section 8, Enforcement Decision Process, was deleted. Chapters 1 to 3 were thus aligned with the FAA Compliance Philosophy order, AFS Compliance Policy notice, and the revised Order 2150.3. AFS personnel must use the new guidance in Chapters 1 through 3 until contrary guidance is corrected throughout Order 8900.1.

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2 See Volume 3, Chapter 60, Section 1.

3 See Volume 11, Chapter 2, Section 1.

4 Refer to Order 2150.3, chapter 2.

5 See Volume 11, Chapter 2, Section 2.

6 See Volume 7, Chapter 1, Section 2.

7 Refer to Order 2150.3, chapters 2 and 7 and appendix H.

8 See Volume 11, Chapter 1, Section 1.

9 Refer to 49 U.S.C. § 44701(d)(1)(A).

10 More information at https://my.faa.gov/org/staffoffices/AOA1/Strategic_Initiatives_Group.html.

11 Foundational skills and expectations will be addressed in detail in a future revision to this order in Volume 1. Until then, the AFS Director’s expectations for interdependence, critical thinking, and consistency are available at https://my.faa.gov/org/linebusiness/avs/offices/afs/afs1_monthly_msgs.html.

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12 See Volume 14, Chapter 3, Section 5.

13 See training resources listed in subparagraph 14-1-1-13D.

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14 We must never act arbitrarily or before considering all facts and circumstances. For example, an in-flight emergency may be a mitigating factor. See Volume 14, Chapter 3, Section 7.

15 Foundational skills and expectations will be addressed in detail in a future revision to this order in Volume 1. Until then, the AFS Director’s expectations for interdependence, critical thinking, and consistency are available at https://my.faa.gov/org/linebusiness/avs/offices/afs/afs1_monthly_msgs.html.

16 For additional information, see the Global Aviation Information Network (GAIN) 2004 publication, A Roadmap to a Just Culture, at http://flightsafety.org/files/just_culture.pdf and http://www.skybrary.aero/index.php/Just_Culture.

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17 ASI compliance and risk mitigation tools (which can be used together or in combination per policy) include: communicating risks to certificate holders verbally and in writing, including making recommendations/suggestions; revising or withdrawing approval for operations specifications (OpSpecs), programs, manuals, or other authorizations and limitations; retargeting and/or increasing surveillance; elevating issues for higher-level AFS support or additional resources; Compliance Actions per this volume; and Enforcement Actions per this volume and Order 2150.3.