7/26/17

 

8900.1 CHG 422

VOLUME 14  COMPLIANCE AND ENFORCEMENT

CHAPTER 1  FLIGHT STANDARDS SERVICE COMPLIANCE POLICY

Section 2  Flight Standards Service Compliance Action Decision Procedure

14-1-2-1    GENERAL. The Federal Aviation Administration’s (FAA) central mission is to promote safety in civil aeronautics. The agency establishes regulatory standards and requirements in Title 14 of the Code of Federal Regulations (14 CFR) parts 1 through 199 under the statutory authority in Title 49 of the United States Code (49 U.S.C.), Subtitle VII. Under 49 U.S.C. § 40113, the FAA Administrator has broad authority to take action that the Administrator considers necessary to carry out his or her statutory responsibilities and powers relating to safety in air commerce, including conducting investigations; prescribing regulations, standards, and procedures; and issuing orders.

A.    Purpose. This section provides the structure to guide Flight Standards Service (AFS) personnel through AFS Compliance Policy implementation. It outlines the process to address deviations from rules, standards, or procedures, resolve them, and return the individual or entity to full compliance. This decisionmaking structure requires an open and transparent exchange of safety information to correct noncompliance and ensure that the risk of recurrence is acceptably mitigated. The exchange of information should occur during interviews, in written statements, and in reviewing and providing supporting documentation, etc.

B.    Scope. The use of Compliance Action (CA) is the initial means of addressing all alleged, suspected, or identified instances of noncompliance. (See paragraphs 14-1-2-7 and 14-1-2-9 for specific Aviation Safety Action Program (ASAP) and Voluntary Disclosure Reporting Program (VDRP) requirements). CAs will be used to correct all noncompliance and deviations until a determination is made that CA is not appropriate. This includes apparent violations of regulations and/or statutes as well as deviations from other established standards or procedures. AFS personnel must keep the following in mind during all interactions with airmen and entities:

Indicates new/changed information.
1)    Except as described herein, where older AFS policy conflicts with Volume 14, Chapter 1, Sections 1 and 2, this newer policy must be followed until it is superseded.
2)    When in doubt as to the appropriate course of action or policy to follow, aviation safety inspectors (ASI) should work through their Front Line Managers (FLM) and office managers with the appropriate policy owners for clarification.

C.    Background. Volume 14, Chapter 1, Section 1, provides important background and reference information on the FAA Compliance Philosophy (CP) and the evolution of AFS Compliance Policy and CA. Pilot’s Bill of Rights (PBR) notification must be provided as described in Volume 14, Chapter 1, Section 1, subparagraph 14-1-1-11G, and Volume 14, Chapter 1, Section 3.

14-1-2-3    TASK PREREQUISITES AND SIGNIFICANT INTERFACES. This task requires use of critical thinking, working interdependently, and completion of formal and on-the-job training (OJT) for Compliance and Enforcement (or later replacement courses).

A.    Significant Interfaces:

    Airmen/organizations/others involved with the apparent noncompliance or deviation;

    FLMs and office managers;

    Principal inspectors (PI) and other certificate management personnel; and

    Policy owners.

B.    References (current editions):

Indicates new/changed information.
1)    FAA Order 8900.1:

    Volume 1, Chapter 2, The Federal Aviation Administration and Flight Standards History, Organization, and Regulatory Responsibilities.

    Volume 1, Chapter 3, Inspector Responsibilities, Administration, Ethics and Conduct.

    Volume 3, Chapter 19, Section 14, Safety Assurance System: Remedial Training and Tracking—Part 121 Pilots.

    Volume 3, Chapter 60, Procedures for Aviation Safety Inspector Decisionmaking.

    Volume 5, Chapter 7, Reexamination of an Airman.

    Volume 7, Chapter 2, Instructions for Investigating a Vehicle/Pedestrian Deviation (V/PD) by a Mechanic Taxiing an Aircraft on an Airport’s Movement Area, Section 1, General.

    Volume 10, Safety Assurance System Policy and Procedures.

    Volume 11, Chapter 1, Section 1, Voluntary Disclosure Reporting Program for Air Carriers and Regulated Entities.

     Volume 11, Chapter 2, Section 1, Safety Assurance System: Aviation Safety Action Program.

    Volume 14, Compliance and Enforcement:

    Chapter 1, Flight Standards Service Compliance Policy.

    Chapter 2, Investigation and Enforcement-Related Tasks.

    Chapter 3, Special Considerations.

    Appendices.

    Volume 15, Chapter 6, Section 1, FAASTeam Program Manager/Regional FAASTeam Point of Contact Duties and Roles to Facilitate Remedial Training.

Indicates new/changed information.

    Any task that identifies an apparent noncompliance or deviation.

2)    Other Documents:

    FAA Program Tracking and Reporting Subsystem (PTRS) Procedures Manual (PPM) (which includes information on releasability under the Freedom of Information Act (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.

    Pertinent Federal aviation statutes and regulations.

C.    Additional Policy Guidance (current editions):

    FAA Order 2150.3, FAA Compliance and Enforcement Program.

    FAA Order 8000.88, PRIA Guidance for FAA Inspectors.

    FAA Order 8000.373, Federal Aviation Administration Compliance Philosophy.

D.    Definitions.

1)    Actions for Organizations. This includes improvements to systems, procedures, operating practices, or training programs. This also includes restricting or removing authority through operations specifications (OpSpecs) to manage operational risk in the public interest, and communicating risk to the certificate holder. FAA actions for regulatory deviations may be documented in PTRS using the *752 “OTHER” or *753 “CONVENE SAT” CA activity numbers.
2)    Additional Training. Any training for individuals remediated through their organization’s approved training program, through another required training program for their job function or work environment (such as carrier or repair station employees receiving Security Identification Display Area (SIDA) or ramp driver training from the airport), or the FAA Safety Team (FAASTeam) remedial training (RT) process. See subparagraph 9) below for the definition of RT and Volume 14, Chapter 3, Section 2 for additional information.
3)    Compliance Action (CA). Action taken by AFS personnel (not the certificate holder) to (1) correct an airman/organization/noncertificated person’s deviation from standards when the deviation was not a result of intentional, reckless, or criminal behavior, or a pattern of negative behaviors or performance; or (2) communicate nonregulatory safety hazards, risks, concerns, or recommendations. See subparagraph 14‑1‑2-7D1) for exclusions.

NOTE:  Distinct CA PTRS records are only created to document regulatory deviations. When a nonregulatory or nonstatutory deviation or safety recommendation/concern is documented in the PTRS, it must be distinguished from regulatory/statutory deviations per subparagraph 14-1-2-9B. The recommendation/concern comment may be made in the PTRS or Safety Assurance System (SAS) record for the underlying activity which led to the discovery, or added to a related regulatory CA activity record.

4)    Corrective Action. Action taken by airmen/organizations/noncertificated persons (not AFS personnel) to correct a noncompliance with a rule or deviations from standards or procedures and to mitigate hazards/risks.
5)    Counseling. Oral or written counseling of airmen, organization personnel, or noncertificated National Airspace System (NAS) participants such as passengers. The common practice of counseling may be used by an ASI at any appropriate time to clarify a person’s understanding and convey regulatory information, best practices, or safety concerns/issues, including the recommendation of additional training or education where no regulatory deviation occurred. However, PTRS CA Counseling *750 activity records are only created for deviations from statutory or regulatory standards.
6)    Education. Providing or making referrals to safety, training, or other aviation educational resources, such as those found at FAASafety.gov or other publicly available sources, to share best practices or recommend additional study in areas of identified risk. Education is recommended when knowledge, skill, or system/process improvements would be beneficial. It can be used in conjunction with a CA or Enforcement Action, or recommended when no regulatory/statutory deviation has occurred.
7)    Enforcement Action. Formal administrative and legal enforcement actions taken in accordance with Volume 14, Chapter 2 and Order 2150.3. Enforcement Actions are not CAs as described in this order.
8)    On-the-Spot Correction. A quick fix of a simple mistake or other apparent deviation which does not require additional followup. The fix must be observed or verified by the ASI. Examples include adding missing information or a signature to an incomplete form; retrieving a certificate from home or receiving temporary authority from the Airmen Certification Branch (AFS-760) before exercising certificate privileges; stowing luggage or equipment blocking an emergency exit; correcting an incorrect instrument setting; or installing missing fasteners. On-the-spot may be selected any time it is used within SAS; however, a PTRS CA on-the-spot *751 activity record is only created for deviations from statutory or regulatory standards.
Indicates new/changed information. Indicates new/changed information.
9)    Remedial Training (RT). A form of CA which uses education and training to allow airmen who have committed an inadvertent apparent deviation to enhance their knowledge and skills. RT is a program authorized as described in Volume 14, Chapter 3, Section 2 and administered by the FAASTeam per Volume 15, Chapter 6, Section 1 that ASIs recommend for certificated airmen when training is the appropriate action to take for a deviation from statutory or regulatory standards. Use of RT requires coordination between the referring ASI and the FAASTeam through office management. RT as defined above generally excludes airmen who were using their certificates subject to an approved training program at the time of the apparent deviation. Those airmen should be remediated through their organization’s approved training program. See documentation instructions in subparagraph 14-1-2-9F4)h) and Volume 14, Chapter 3, Section 2 for additional information and exceptions.

E.    PTRS and SAS Reporting. CAs used to correct statutory or regulatory noncompliance must be recorded in PTRS using the activity numbers in subparagraph 14-1-2-9E. When SAS data collection and surveillance leads to discovery of a regulatory noncompliance, a PTRS record is required to document the CAs taken to correct the issue in addition to the SAS documentation required by Volume 10.

14-1-2-5    PROCESS FLOW MAP.

Figure 14-1-2A.  Compliance Action Decision Process

Figure 14-1-2A. Compliance Action Decision Process

14-1-2-7    PROCEDURES.

A.    Notification. Communication at initial notification should match the specific facts and circumstances. For example, the immediate verbal notification provided during a ramp check that results in an on-the-spot correction may be all that is necessary. However, significant safety hazards and ongoing operational risks discovered during surveillance of an organization would likely require immediate contact via telephone or other means, and be followed up in writing (through the PI, when appropriate).

1)    Address Immediate Safety Concerns. ASIs should take immediate action to mitigate significant safety hazards and ongoing operational risks. Therefore, when an ASI becomes aware of an immediate safety concern, he or she must take timely steps to notify the airman or responsible person who can take the appropriate action to prevent it from continuing.
2)    Non-Immediate Issues. ASIs have more time to fully understand actual or apparent deviations that have terminated (e.g., pilot deviations) where no immediate threat to the NAS exists. In these cases, the ASI may exercise judgment on whether or not it is prudent to immediately contact the airman or responsible person.
3)    PBR. For transparency, a CP and PBR Brochure (see Appendix 14-1, Compliance Philosophy and Pilot’s Bill of Rights Brochure) has been developed and must be used when conducting CA investigations. Formal notification with a Letter of Investigation (LOI) (including PBR text for airmen) is only required for Enforcement Action (see Volume 14, Chapter 1, Section 1, subparagraph 14-1-1-11G and Volume 14, Chapter 1, Section 3 for due process and the CP/PBR Brochure).
4)    Coordination. If the event involves an organization, the ASI must notify the appropriate oversight office concerning the noncompliance and any action that was taken to address an immediate safety concern. The oversight office may take over and continue the appropriate process. In all cases, ASIs should work interdependently, keep their FLM informed appropriately, and coordinate any follow-up communication with the PI/certificate-holding district office (CHDO).
5)    Checking Compliance History. ASIs must check surveillance, CA, and enforcement histories of certificated and noncertificated persons/entities prior to making or communicating final CA decisions. This does not preclude an ASI from making an on-the-spot-correction or providing immediate counseling. In all cases, the ASI must inform the person/entity that further action may be required after history is checked.
6)    Timely Processing. In all cases, the goal is to restore compliance now and for the future. Regardless of whether the event requires immediate notification to the regulated entity, the remaining procedures in this section should be completed in a timely manner. When addressing regulatory and/or statutory noncompliance, it is important to determine eligibility for CA as early as possible and to determine the appropriate type of correspondence needed with the airman/entity. For airmen, the National Transportation Safety Board (NTSB) 6-month-stale complaint rule1 applies if certificate action is to be taken. The ASI should keep their FLM informed of their activities and, when applicable, coordinate certificate holder communication with the PI/CHDO.
7)    ASAP Considerations. The investigating ASI must determine whether the entity has an ASAP covering an involved employee group by accessing the AFS ASAP web page at http://www.faa.gov/about/initiatives/asap/media/asap_participants.pdf. See Volume 11, Chapter 2, Section 1 for more CHDO coordination information.
8)    Initial Documentation Considerations. When FAA action is necessary to correct a regulatory deviation, the appropriate CA or Enforcement Action PTRS record should be created (although not necessarily completed) within 3 business-days of the ASI’s determination per PPM guidelines.2

B.    Investigate, Analyze, and Assess the Problem. The procedures in this paragraph are designed to aid in the Root Cause Analysis (RCA) of the apparent deviation. FAA safety personnel must identify who did what, where, when, and why. Determining why the event happened and identifying the underlying root cause(s) is the purpose of the investigation. Compliance will only be ensured if the cause(s) of the event are clearly established, understood, and corrected. When a regulatory deviation is identified and associated with an entity, the ASI must consult with the PI/CHDO to make this assessment, or provide information for the PI/CHDO to make the assessment.

NOTE:  ASIs must continue to gather information and remain engaged with the responsible parties in order to conduct a thorough and unbiased investigation.

1)    Gather the Facts. Consider taking the following suggested actions, based on the ASI’s determination of the information needed in each specific situation. This list is neither mandatory nor all‑inclusive:
a)    Reviewing records, including air traffic control (ATC) forms and data from the Knowledge Services Network (KSN).
b)    Reviewing technical documents (e.g., manufacturer’s maintenance manuals, Airplane Flight Manual (AFM), or Rotorcraft Flight Manual (RFM)).
c)    Interviewing the party or parties involved (acquiring witness statements, if necessary).
d)    Acquiring technical information from other agencies (e.g., the National Weather Service (NWS) and ATC).
e)    Inspecting and taking photographs of items associated with the event, including physical evidence such as skid marks or damaged parts.
2)    Ask the Questions. Consider the following suggested lines of inquiry, based on the ASI’s determination of the information needed in each specific situation. This list is neither mandatory nor all‑inclusive:
a)    Objective description of the event: what happened?
b)    What possible outcome(s) could have resulted?
c)    Why did the people involved select that course of action?
d)    What was the operation being done or attempted?
e)    What was the expected process/procedure?
f)    What information was available to the individual(s) involved about the task/operation?
g)    What were the conditions?

    Workload;

    Task complexity;

    Distractions;

    Personal and organization interfaces;

    Physical working environment;

    Competency of individual(s) involved (i.e., knowledge, training, experience related to the task/operation);

    Availability, quality, and clarity of technical and procedural information;

    Availability of supervision or consultation with others;

    Adequacy of resources (e.g., tools, facilities, personnel, supplies);

    Constraints (equipment; time; environmental conditions; other rules, e.g., environmental, occupational); and

    External pressures (e.g., time pressure, production, service demands, and organizational policies).

h)    What controls were in place?

    Controls that could have prevented the error/failure; and

    Remaining controls that prevented the error/failure from having a more severe outcome.

i)    Why were the controls that failed ineffective (in the opinion of the interviewee or the evaluator conducting the analysis)?
j)    Recommendations for improvement (in the opinion of the interviewee or the evaluator conducting the analysis).
3)    Analyze the Event.
a)    Critical thinking involving careful, objective analysis is the key to understanding the event. Analysis of each event should focus on determining the nature of the problem, the conditions under which it occurred, the controls that failed (and may fail again in the future), and the most effective proposed corrective action(s).
b)    Before deciding on CA as the mitigation, determine if the airman/organization is proactive, cooperative, and capable of participating in effective corrective or preventive action. An inability to comply requires a more formal process of correction.

NOTE:  An entity’s refusal to speak with the FAA, or the obtaining of legal counsel, does not automatically rule out CA. Airmen and organizations are free to exercise their rights without repercussions. An entity that complies with FAA requirements to regain and maintain compliance is considered cooperative. However, if the ASI cannot adequately determine the facts of the case, or cannot identify appropriate remediation(s) that are consented to and successfully accomplished by the involved parties, the ASI must still use due diligence on behalf of the public’s safety interest. Such due diligence may include reexamination, re-inspection, or suspension pending compliance to determine that the certificated entity is qualified, competent, and proficient.

c)    The determination must be based reasonably on observable behaviors and the facts and circumstances in each case.

    Does the airman/organization consistently perform in a positive manner toward regulatory requirements?

    Does the airman/organization understand or recognize its role in the deviation?

    Does the airman/organization cooperate with FAA personnel to achieve compliance?

    Does the airman/organization take the necessary actions to come into and maintain compliance?

    Are there repeated failures to take corrective actions or repeated deviations?

    Is the airman/organization noncompliant in more than one area? Does it involve multiple personnel?

NOTE:  The fact that multiple areas or personnel are involved may indicate a management or system failure (unsatisfactory supervision/procedures, misplaced priorities, goal conflicts, etc.).

d)    ASIs should assess all available facts and circumstances associated with current and previous deviations. ASIs should evaluate the event for possible systemic issues; this is particularly important for a frequently cited regulation.
e)    Depending upon the specific circumstances associated with each event, repeated deviations from the same regulation may not indicate a common systemic failure. Often on the surface it appears that the same regulation is being repeatedly violated due to the broadly defined wording of most regulations. However, every situation has a unique set of facts. A review of the specific circumstances may find that the deviations are due to entirely different causes.
f)    Effective corrective action begins by clearly defining the real problem. Additional CA can be taken in cases where the actual root cause was not previously identified and addressed. Recurring findings often happen because an organization:

1.    Solved the wrong problem;

2.    Fixed the outcome only;

3.    Fixed the symptoms only; or

4.    Corrected only one problem, when two or more problems exist.

C.    Is There Compliance? Once the problem is completely understood, review the regulations applicable to the event. The following question can now be answered: Is there regulatory and statutory compliance?

1)    If Yes (A Regulatory/Statutory Deviation Did Not Occur). The CP and policy should be applied to address safety concerns in the NAS where no clear regulatory requirement exists.3 AFS personnel can communicate or transfer risks and make recommendations to regulated and nonregulated entities and document those AFS actions as described in this section. Document these nonregulatory concerns, potential risks, or recommendations in the PTRS (and/or SAS as appropriate) within the activity that led to the discovery per subparagraph 14-1-2-9B. Include all ASI and/or certificate holder actions to communicate or transfer the concerns/potential risks and to correct the identified problem(s). Coordinate communication to the certificate holder with the PI/CHDO and notify the PI, CHDO, and/or the FLM of any concerns or risks. In communications with the certificate holder, clearly identify that FAA concerns/recommendations are to make improvements or use best practices, but they are not regulatory requirements.
2)    If No (A Regulatory/Statutory Deviation Did Occur). Determine the most efficient and effective course of action to reestablish compliance. CA should be used if the individual or entity sufficiently meets the criteria of subparagraph 14-1-2-7B3) above, and the noncompliance does not entail intentional, reckless, or criminal behavior (see Volume 14, Chapter 1, Section 1, subparagraph 14-1-1-7E).
Indicates new/changed information.
3)    Additional Considerations for Regulatory/Statutory Noncompliance.
a)    For events that have ceased, the question, “Was There Regulatory/Statutory Compliance,” is still appropriate to ask in this step. The noncompliance does not have to be occurring at the present time in order for a CA to be documented.
b)    There may be instances where an ASI becomes aware of a deviation that has occurred after the airman or responsible person has taken steps to address the noncompliance and prevent its reoccurrence. The procedures in this section must still be completed (in coordination with the PI/CHDO, when applicable) to decide if the appropriate fix to the problem has been applied, to determine if any validation or followup surveillance is needed, and to document the issue.

1.    If sufficient corrective action has been taken or implemented by the airman or responsible person, the ASI can document the action(s) using the *752 “Other” PTRS activity code.

2.    Determine whether additional validation or followup surveillance is needed and plan/document accordingly. This should be done in coordination with the PI/CHDO when applicable.

3.    If the corrective action taken by the airman or responsible person is not adequate to the address the underlying root cause(s) of the noncompliance, the ASI may take additional action as described in this section.

D.    Is CA Appropriate?

1)    Potential Exclusions. CA may not be appropriate based on the specific facts of the event under review, or because of other policies or commitments that require a different agency response, as described in Volume 14, Chapter 1, Section 1 and this section. AFS must follow policy and process commitments made to Congress, the Inspector General (IG), and other external parties. Examples include, but are not limited to, Airworthiness Directives (AD),4 ASAPs,5 Aviation Safety Reporting Program (ASRP),6 flight operations quality assurance (FOQA),7 all noncompliance by military and foreign pilots,8 Special Emphasis Enforcement Programs,9 and VDRPs.10 See subparagraphs 14-1-2-7A7) and 14-1-2-9A for additional ASAP and VDRP requirements, and Volume 14, Chapter 1, Section 1, subparagraph 14-1-1-7E on enforcement action.
2)    If Yes (CA Is Appropriate). Take appropriate CA, such as:
a)    On-the-spot correction, counseling, or education;
b)    Additional training (requires interface with PI/CHDO when applicable), or RT for airmen;
c)    Improvements to systems, procedures, operational practices, or training programs for regulated entities (requires interface with PI/CHDO);
d)    Documenting corrective action that may have already been initiated or implemented by the airman or entity; and
e)    Any other action that would correct the noncompliance and address the underlying safety concern.
3)    If No (CA Is Not Appropriate). Take appropriate action. Refer to Volume 14, Chapter 2, and Order 2150.3 to initiate Enforcement Action.

E.    Is the Problem Fixed?

1)    Plan Followup Surveillance Activities. The ASI will validate CA, or Enforcement Action, effectiveness when necessary.
a)    Followup is normally not needed for simple mistakes, lack of understanding, or diminished skills which have been corrected with on-the-spot corrections, oral/written counseling, or (for General Aviation (GA) airmen) RT completed per Volume 15, Chapter 6.
b)    Company program, manual, or procedure changes normally require followup to validate that the change is put in place and that it has the intended result (coordinate with the PI/CHDO). If followup activities have been created and linked to the original CA or Enforcement Action record in comments and there is no other reason to keep the original record open, the original record may be closed.
c)    The ASI must consult on proper followup and documentation with his or her FLM when complex or long-term followup is needed, and with the appropriate PI/CHDO when an air agency/carrier/operator or letter of authorization (LOA) holder is involved.
2)    If Yes (The Problem Is Fixed). Close the CA PTRS with documentation, as described in paragraph 14-1-2-9.
3)    If No (The Problem Is Not Fixed). Is further CA appropriate and warranted?
a)    If yes, document within PTRS the additional CAs necessary to ensure the effectiveness of root cause fixes. Continue followup.
b)    If no, then an unsuccessful CA has occurred (e.g., the airman chooses not to participate, is unable to take effective corrective action, or new information/behavior makes CA inappropriate). Terminate the CA PTRS record and initiate Enforcement Action in accordance with Volume 14, Chapter 2, and Order 2150.3. Trigger the enforcement PTRS record from the CA PTRS record. (See additional PTRS documentation requirements in paragraph 14-1-2-9.) Regardless of the enforcement action outcome, continue communicating with the certificate holder to mitigate the safety issues involved to an acceptable level (i.e., return the certificate holder to compliance and prevent recurrence).

NOTE:  Unless opened in error (see subparagraph 14-1-2-9K), a terminated CA requires Enforcement Action. (See Volume 14, Chapter 1, Section 1, subparagraph 14-1-1-11G and Chapter 1, Section 3 for the CP/PBR Brochure and due process considerations and subparagraph 14-1-2-9I for additional policy on Compliance Actions with Unsuccessful Corrective Action Completion.)

F.    External Communication/Correspondence. The steps discussed in the Compliance Action Decision Process (CADP) are meant as an aid for addressing noncompliance. Based on the particulars of each case, AFS personnel are expected to use the most efficient and effective means to find and fix the safety issue(s). AFS personnel must use critical thinking and interdependence to determine the appropriate level of external communication/correspondence necessary for each situation and the specific facts involved. Refer to the communication/correspondence guidelines in Appendix 14-3, Compliance Action Communication/Correspondence Guidelines.

1)    The following information must be conveyed during verbal communications and/or written correspondence concerning a CA (except when there is repeated communication/correspondence with the same entity and the information below has already been conveyed):
a)    Initial communication and/or correspondence:

1.    A statement that the event appears eligible (or may be eligible) for CA.

2.    A statement that enforcement action is not being pursued based on known information.

b)    Completion of a CA. A statement that the event has been closed as a CA describing the type of action taken.
2)    Corrective actions that take time or are complex in nature should be documented in writing (email or letter as appropriate to the facts and circumstances), including FAA expectations and clear suspense dates for responses.
3)    Communication/Correspondence to an organizational entity that extend beyond addressing the immediate safety concerns must be coordinated with the appropriate PI/CHDO.
4)    If an email or letter is sent to an individual (not an organizational entity) requesting information, the CP/PBR Brochure (see Appendix 14-1) and the Privacy Act Notice (see Appendix 14-2, Privacy Act Notice) should be included.
5)    Follow existing AFS and office policies for correspondence and record retention.

NOTE:  Under the current expunction policy and retention schedule, there is no authority to destroy records related to CAs.

14-1-2-9    PTRS/SAS CA RECORD DOCUMENTATION REQUIREMENTS.

A.    ASAP and VDRP Data Protected from Disclosure. An impediment to further development of voluntary information sharing programs is the reluctance of some persons to share information that may later be released through a FOIA request or other means. For that reason, the legal protections cited below were put in place.

1)    All records submitted to the FAA for review regarding ASAP, including information predicated upon the ASAP report, are protected from release to the public in accordance with the provisions of the current edition of FAA Order 8000.82, Designation of Aviation Safety Action Program (ASAP) Information as Protected from Public Disclosure under 14 CFR Part 193.
2)    All records submitted to the FAA for review regarding VDRP, including information submitted via the web-based VDRP system, are protected from release to the public in accordance with the provisions of the current edition of FAA Order 8000.89, Designation of Voluntary Disclosure Reporting Program (VDRP) Information as Protected from Public Disclosure under 14 CFR Part 193.
3)    For the reasons cited above, no CA PTRS records will be completed for an accepted ASAP or VDRP event. ASAP and VDRP corrective actions documentation and PTRS requirements for accepted and excluded reports are detailed in Volume 11 and Volume 14, Chapter 3, Section 12. Additional information on ASAP and VDRP documentation is found in N 8900.352.
Indicates new/changed information.

B.    Documentation for Nonregulatory/Nonstatutory Issues or Events. As noted in Figure 14-1-2A, Compliance Action Decision Process, there is the potential for an ASI to have concerns or recommendations, following a surveillance or other encounter with an airman or other entity, that do not involve regulatory or statutory noncompliance.

1)    If there are no other regulatory/statutory findings, do not create a CA PTRS record. These concerns/recommendations are documented in the primary activity record (in the appropriate SAS comment field as described in the next paragraph, or in the surveillance or other PTRS record). In both SAS and PTRS, clearly identify and document these nonregulatory concerns/recommendations in a comment (in PTRS, using a separate comment with the appropriate primary area code, a keyword list of “911,” and an opinion code of “I”). If CA is taken for other regulatory or statutory findings, additional concerns/recommendations may be documented in the same CA PTRS record in a separate comment coded as described above. Documenting these concerns will help the FAA identify potentially systemic issues during future activities.
2)    Nonregulatory safety concerns and/or recommendations with no apparent regulatory or statutory deviation are documented in the SAS record for the underlying activity that led to identification of the concern (such as a Design Assessment (DA)/Performance Assessment (PA) or random inspection (RI)) in accordance with Volume 10 policy using the “Inspector Action Taken” field when available, or the “Supporting Comments” field.
3)    See additional documentation requirements in subparagraph 14-1-2-9F below.

C.    General Requirements for Documenting Regulatory/Statutory Deviations. All CAs for regulatory or statutory deviations (by all ASIs, including those primarily using SAS) will be documented with a PTRS record using the activity numbers in subparagraph 14-1-2-9E and as outlined in the PPM. A distinct PTRS record will be created for each airman and organization involved. Multiple specific CAs for the same airman/entity may be used when appropriate. If at least one specific CA activity number is used, any additional actions for the same certificate holder or person may be documented with separate comments in the same PTRS record.

1)    When a CA PTRS is completed, the comments must provide a description of the problem, the overall planned corrective action, and show how the deviation was permanently fixed, which may require linking the record to future followup activities.
2)    ASIs must make quality entries and FLMs must verify that all CAs recorded in PTRS answer the questions of “Who, What, When, Where, and Why,”11 including each root cause that led to the deviation. Once the cause(s) are clearly identified and documented, the comments must document the immediate as well as long‑term corrective actions (see subparagraphs 14-1-2-7E1) and 14-1-2-9H for discussion of followup). 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. The answers to these questions and requirements should be readily identifiable. A complete and comprehensive report demonstrates that a quality work activity was performed.

D.    Multiple Records Requirement. PTRS records used to document the CA are not a replacement for the record used to document the primary activity (such as surveillance or accident investigation) during which the deviation was found.

1)    If an ASI finds a deviation during (for example) a routine facility inspection (other than a joint audit per Volume 11) and determines that CA is appropriate to address the deviation, then the ASI would complete a PTRS record for both the facility inspection and the CA.
a)    The PTRS generated for the CA should be triggered from the PTRS record for the primary activity. The parent transmittal record ID number will appear automatically in the “Related Record” field of the triggered CA record.
b)    The ASI must manually enter tracking of triggered record(s) in the parent record. The activity number(s)/record ID(s) of the triggered record(s) should be entered in the comment section using the appropriate Primary Area, Keyword “907,” and Opinion Code “I,” per the PPM, Chapter 4, Recording PTRS Activities. Refer also to the PPM, Appendix B, How to Tie Records to Their Followups, for triggering and linking records.
c)    The parent surveillance or other PTRS record which led to the discovery is closed with a results code of “F” for followup when CA(s) is (are) taken. The parent record may be closed before the CA is completed.
d)    If, however, any enforcement action is taken as an initial result of the parent activity, the parent PTRS record is closed with a results code of “E” for enforcement. Multiple actions for one event, such as separate enforcement actions for a company and captain and a CA for a first officer, are triggered (if possible) from the same parent PTRS record.
2)    There may be instances where it is appropriate to take a CA to address noncompliance for an organization, and, additionally, take CA for personnel working for that organization. Separate CA PTRS entries are created for each entity or person that receives a CA. If possible, trigger the CA PTRS records from the single parent record as described in the paragraph above. Coordinate any followup and non-immediate communication with the PI/CHDO when applicable.

E.    Appropriate Activity Code. Choose the appropriate PTRS INVESTG/COMPLIANCE ACTION to document responses to the regulatory or statutory deviations. (See subparagraph 14-1-2-9B for documenting nonregulatory responses.) See definitions in subparagraph 14-1-2-3D for additional information. Activity Numbers are as follows, with the asterisks representing a 1, 3, or 5 (Operations 1000-series, Maintenance 3000‑series, and Avionics 5000-series):

NOTE:  CA PTRS records will not be created for accepted ASAP or VDRP reports.

1)    *749 Additional Training. All additional training processes documented by non-FAASTeam ASIs per this order. See Volume 14, Chapter 3, Section 2, for additional information and see RT documentation instructions in subparagraph 14-1-2-9F4)h).
2)    *750 Counseling. Applies to any person participating in the NAS. Used to document oral or written counseling of individuals for deviations from regulatory or statutory standards.
3)    *751 On-the-Spot Correction. Used to document correction of regulatory or statutory deviations that meet the subparagraph 14-1-2-3D definition.
4)    *752 Other. For regulatory CAs that do not fit in another specific category. May also be used when appropriate to document corrective action(s) initiated or completed by airmen/organizations prior to the FAA’s discovery of the deviation.
5)    *753 Convene SAT. Used by SAS ASIs only when choosing to convene a System Analysis Team (SAT) in response to a safety concern or deviation.

F.    Required Fields. Complete all required fields in the PTRS record and include the following information in accordance with the PPM chapter 4.

NOTE:  Unless discovered and documented in SAS as described in subparagraph 14-1-2-9G, nonregulatory safety concerns and/or recommendations with no apparent regulatory or statutory deviation are documented in the PTRS record for the activity that led to the discovery using the same criteria below for regulatory noncompliance, except where noted below.

1)    Section I: “Who” was involved; the four-letter designator for an entity or the certificate number and name for an individual airman.
2)    Section II: Include additional relevant personnel information (such as an instructor or additional crewmember involved) as described in the PPM at page 4-17, subparagraph B, including any certificate number(s) in the “Remarks” field (additional “Who” involved).
3)    Section III: Include any relevant information.
4)    Section IV: Include comments which document the following:
a)    “What” happened: Describe the noncompliance event, the specific regulatory requirement (SRR) (including the rule or statute citation), and how the requirement was not met. Include additional “When” and “Where” details not captured in Section I, and explain the role of all personnel involved or listed in Section II. For nonregulatory safety issues, concerns, or recommendations, the SRR is not required; describe what happened to raise the issue.
b)    All identified hazards or ineffective risk controls, including behaviors, that led to the issue.
c)    (Regulatory findings only.) “Why” it happened: A brief summary of the analysis and a listing of the underlying root cause(s) that resulted in noncompliance. The ASI should critically review and validate any analysis or root cause(s) provided by a certificate holder.
d)    The mitigating or corrective action(s) taken by the person/entity to correct the problem, if any, and when those action(s) were taken.
e)    (Regulatory findings only.) Whether the person/entity completed all corrective action(s) to the FAA’s satisfaction.
f)    Whether any other FAA action was taken or is still required (additional followup, reexamination/re-inspection, enforcement, etc.), including the ASI’s recommendations on the controls, monitoring, and feedback required to mitigate risks and ensure compliance.
g)    If applicable, document use of SAS risk management process (RMP) or SAT. See the definition in subparagraph 14-1-2-9G2) specific to the “Convene SAT” PTRS activity.
h)    If used, RT under Volume 15 must be noted in the *749 “Additional Training” CA PTRS record comment section, including details of the referring ASI’s offer of RT and acceptance by the airman and the FAASTeam Program Manager’s (FPM)/Regional FAASTeam Point of Contact’s (RFPOC) *950 PTRS activity’s full record ID number. The referring ASI’s record must remain open until the RT process outcome is known from the FPM/RFPOC and documented by the ASI in the “Additional Training” record. See Volume 14, Chapter 3, Section 2, and Volume 15, Chapter 6, Section 1 for additional instructions.
i)    If applicable, related PTRS records must be linked with coded comments per subparagraph 14-1-2-9D1) above (keyword “907-I”).
j)    When completed, ASIs should review the record(s) and subparagraphs 14-1-2-9C1) and 14‑1‑2-9C2) to verify they have completed an adequate compliance history record for future review as to what the problem was and how it was fixed.

G.    SAS Instructions. CA PTRS records recorded in SAS comment fields will include “CAPTRS” (without quotes or spaces) and the full record transmittal ID number as shown in this example: CAPTRSEA61201512345.

CAPTRS

EA61

2015

12345

Compliance Action PTRS

Office Code

Year created

Unique record identifier

1)    SAS users must use CA and document PTRS numbers in accordance with Volume 10, Chapters 5 and 6, and Volume 14.
2)    If a SAT is used, create a “Convene SAT” PTRS record with sufficient comments to describe the reason for convening the SAT and to locate the SAT record in SAS. SAT activities and outcomes only need to be documented in SAS, not the PTRS record. This will provide PI visibility to the CA within the SAS data, and also office/national visibility for identified concerns within the PTRS data.
3)    All SAS ASIs directly conducting surveillance (Module 4, including principal and non-principal personnel) should take appropriate CAs (such as on-the-spot corrections) for regulatory deviations when and where issues are identified. Use the “Inspector Action Taken” field, if available in the Data Collection Tool (DCT) being used, to describe the issue and include CAPTRS and the full PTRS record ID number for CA taken. If that field is not available (i.e., in a Random, En Route, or Custom DCT), use the “Supporting Comments” field. In all instances, the important thing is to fix the immediate safety issue and document it per general Volume 14, Chapter 1, Section 2 and Volume 10 guidance in PTRS. Notify the PI per Volume 10, Chapter 5, Section 1.
4)    PI: During Module 5 Analysis, Assessment, and Action (AAA), the PI identifies issues requiring action/followup and tracks them with the Action Item Tracking Tool (AITT), which may include a CAPTRS created and entered in Module 4 by the PI or another ASI. When a PI identifies a new regulatory deviation from AAA requiring additional action or followup, the PI creates a new CA record and enters “CAPTRS” and the full PTRS record ID number in the AITT in the “Explanation” field, under “Action Justification.” When the PI assesses a regulatory deviation has occurred and selects either a “3 Regulatory Issues” or “4 Regulatory/Systemic Issues,” then the “Action Justification” field and the AITT must contain the PTRS record transmittal ID. See Volume 10, Chapter 6, Section 2.

H.    Followup Surveillance Activities. When additional followup is required and is able to be completed soon by the discovering ASI, the initial CA PTRS record can remain open to document any short- or mid-term followup validation required. For complex or long-term followup, trigger (if possible) any additional followup surveillance activities needed to validate CA effectiveness from the CA PTRS record, then close the CA record as completed with a comment linking it to the planned follow-up activity. (See step E in Figure 14-1-2A.)

1)    If followup confirms compliance, close the PTRS. Document SAS records as described above and in accordance with Volume 10 policy.
2)    If followup fails to confirm full compliance has been restored, reevaluate if CA or Enforcement Action is appropriate. (See step E in Figure 14-1-2A and subparagraphs 14-1-2-7D and 14-1-2-7E above.)

I.    CAs with Unsuccessful Corrective Action Completion.

1)    If agreed-upon corrective action(s) were implemented but failed to achieve their intended purpose, revised or additional corrective actions should be developed and implemented. This is a normal and expected process that should be documented in either the original CA PTRS record comments or in the comments of triggered followup surveillance PTRS.
2)    When the airman/entity fails to complete agreed-upon corrective actions to the FAA’s satisfaction, the ASI documents the situation as follows:
a)    Provide the details in the CA PTRS as described in subparagraph 14-1-2-9F4).
b)    Terminate the CA PTRS record with a “T” in the results code.
c)    Trigger any resulting Enforcement Action PTRS record from the parent CA PTRS record.
d)    Link the records per subparagraph 14-1-2-9D.
e)    Document related FAA and certificate holder mitigation actions in the enforcement PTRS record.

J.    Data Quality Guidelines, Review, and Job Aid.

1)    ASIs must make timely entries that meet the criteria in subparagraph 14-1-2-9F and answer the questions of “Who, What, When, Where, and Why” as described in the PPM. A complete and comprehensive report demonstrates that a quality work activity was performed.
2)    FLMs, or other delegated personnel, must review all regulatory/statutory CA records to assure policy is followed and that records are clear and complete enough to stand alone as useful information when accessed in the future. The answers to the questions and requirements in subparagraphs 14-1-2-9C and F should be readily identifiable to others without first-hand experience with the facts.
3)    Appendix 14-4, Compliance Action Documentation Review Job Aid, contains a job aid and additional references to assist the ASI in creating quality entries, help others perform efficient reviews, and provide a standardized mechanism for providing feedback concerning documentation requirements.

K.    CA Records Opened in Error. If a PTRS record is opened in error, terminate the CA. This may be done when the identified noncompliance is later proven incorrect, when a requirement to take enforcement action is later discovered, or for other reasons requiring the activity to be terminated.

1)    Close the PTRS record with a “T” in the results code.
2)    Provide with explanatory comments including applicable parts of subparagraphs 14-1-2-9F4)f), i), and j). The rest of subparagraph 14-1-2-9F4) no longer applies.

14-1-2-11    TASK OUTCOMES. The completion of this task results in:

    ASIs using critical thinking and working interdependently to find and fix safety problems in the NAS as efficiently and effectively as possible;

    Conserving FAA resources by using 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;

    Increased cooperation from airmen and entities when interacting with ASIs; and

    Increased voluntary compliance with FAA regulations.

14-1-2-13    FUTURE ACTIVITIES.

A.    Analysis and Interdependence. “ASIs should continually analyze data available on their assigned [certificates for] trends, findings or problem areas that may point to issues regarding compliance and that may require corrective actions. Inspectors should also make recommendations to management for changes in [surveillance plans and policies] if adverse patterns, trends, or problem areas are discovered. Inspectors should coordinate their findings with the supervisor and office manager [and the PI/CHDO, when applicable] when potential adverse safety data is detected and make adjustments to their work program as necessary.”12

B.    Enforcement Cases Reconsideration. There may instances where initiated enforcement cases are later determined to be eligible for CA. See Appendix 14-5, Guidance for Review of Enforcement Cases Under the FAA’s Compliance Philosophy, for additional guidance.

C.    Other Activities:

    Continue followup when appropriate to validate that airman/organization corrective actions were effective;

    Search the National PTRS (NPTRS) data for prior CA records and other record keyword 907/911 comments when responding to new suspected or actual airman/organization noncompliance or deviations;

    Review SAS Module 4 and 5 reports and the Short Term Solutions (STS) Reports, especially the SAS Compliance and Enforcement Action Comprehensive Report. Periodic review of these reports can help identify SAS documented CA data (see Volume 10, Chapter 6, Section 1); and

    Initiate Enforcement Action when CA is not appropriate or effective.

14-1-2-15 through 14-1-2-29 RESERVED.



1 Refer to Title 49 of the Code of Federal Regulations (49 CFR) § 821.33.

2 Refer to the PPM, chapter 2, section 2, subparagraph 3F.

3 From Volume 1, Chapter 2, Section 3, subparagraph 1-141C, also consider submitting “safety recommendations in accordance with the procedures outlined in FAA Order 8020.11, Aircraft Accident and Incident Notification, Investigation, and Reporting. If the safety recommendation proposes rulemaking, inclusion of the information required by 14 CFR part 11, § 11.25 aids the appropriate FAA office in responding to the recommendation.”

4 See Volume 3, Chapter 60, Section 1.

5 See Volume 11, Chapter 2, Section 1.

6 Refer to Order 2150.3, Chapter 2, Compliance and Enforcement Policy and Objectives.

7 See Volume 11, Chapter 2, Section 2.

8 See Volume 7, Chapter 1, Section 2.

9 Refer to Order 2150.3, Chapters 2; 7, Sanction Guidance Policies; and Appendix H, Compliance and Enforcement Bulletins.

10 See Volume 11, Chapter 1, Section 1.

11 Refer to the PPM, chapter 4, section 2, paragraph 2.

12 Refer to the PPM, chapter 2, section 2, subparagraph 4C.