Audits and Inspections

The Audit or Inspection Process

Audits

An audit is scheduled check of ACA departmental operations or our contract services providers operations. Audits help to confirm that ACA or our contract services provider’s processes, policies or procedures are compliant with ACA standards and compliant with CAAT requirements.

ACAs audits may also include compliance monitoring. A compliance monitoring audits will be conducted to ensure compliance with CAAT requirements.

Audits are used to confirm that processes, policies, resources, procedures and results are focused and relevant to the ACA’s operation. The main purpose of an audit is to identify unsatisfactory practices before they cause an accident. Audits will be carried out in accordance with the Audit Schedule.

Checklists are required to be completed before conducting Audits. The Quality Audit or Inspection Form is required and shall be delivered to the Head of Quality within 48hr of completing the Audit.

The Head of Quality shall monitor the effectiveness of the Audit Schedule, if required; changes are to be effected through the Quality Assurance Committee review process.

Audit Types

Quality Audits

A Quality Audit is a scheduled and a formal review to evaluate compliance with ACAs quality standards for our processes, policies, procedures, and contractual requirements. Quality audits cover internal, ACA operations, and external, contract service providers operations.

Compliance Monitoring Audits

A Compliance Monitoring audit is a scheduled and a formal review to evaluate compliance with CAAT requirements.

Internal Audits

Internal audits are scheduled and conducted by ACA’s Head of Quality to ensure that ACA’s process, policies and procedures meet the requirements of ACA and that all applicable CAAT are being complied with.

Department Internal Self Audits

All Nominated Persons, department managers and supervisors are encouraged to conduct department internal self audits. This is a tool we employ to measure safety margins of processes, policies and procedures within the department at ACA.

Department internal self audits are still considered a formal process and will follow the processes, policies, procedures and complete all forms that would be used in a scheduled audit.

External Audits

External audits are undertaken by ACA’s quality department to ensure that our contracted service providers process, policies and procedures meet the requirements of ACA and that all applicable CAAT are being complied with.

Follow Up Audits

This audit is required as part of the corrective action verification process.

Management Evaluation Audits

All Nominated Persons are aware that they themselves and the departments that they are subject to audits and inspections to ensure their commitment to ACA’s QAS.

In ACA it is called the Quality Assurance Committee review process and it considers:

• The results of audits or inspections, safety reports, operational analyses and any other information sources.
• The overall effectiveness of the management organization in achieving its stated safety objectives.

The Accountable Manager assumes the overall responsibility for ensuring that all Nominated Persons are committed to ACA’s Quality Assurance System policies, procedures and the constant improvement of safety throughout the company.

Specialist Advice

ACA Auditors and Inspectors cannot be experts in every field related to the operational environment. It is important that they realize their limitations. When necessary, they must be willing to consult with other professionals during an audit or evaluation. ACA may utilize the following specific sources of information:

• Mandatory reporting programs;
• Voluntary Reporting Program;
• The external audit process;
• Accident and incident investigations;
• Data analysis;
• Change management;
• Internal Audit and Inspections;
• Continuous Monitoring

ACA actively seeks the information necessary to confirm the successful operation of our QAS processes. Continuous monitoring involves analysis of operational data as it becomes available. The operational data is continually monitored to discover any pertinent trends. The Head of Quality is responsible to monitor this information and accomplish this review on a weekly basis.

Audit Planning

This form is completed in order to establish the overall audit requirements for a particular year.

The form includes the schedule area and months and whenever an area is required to be audited in the particular month, the area audit code is inserted. To identify which area is to be audited during a particular month, refer to Audit Schedule Plan. A blank space means that there is no audit requirement for the particular area during the month in question.

Document reference at the bottom left indicates the reference for the particular form.

Audit Scheduling

The Quality Assurance System contains audit schedule and periodic review details.

The schedule is flexible and unscheduled audits can be completed when required by adverse trends.

Follow-up audits are scheduled to ensure that corrective action has been effective.

All topics are audited with a frequency no greater than 12 months. Audit frequency should not be extended without the specific agreement of the Authority.

In the event the Audit is not performed according to the Audit plan for the year, the Head of Quality shall decide whether the Audit will be postponed or cancelled.

The schedule for each defined area shall include:

1. The Month of Audit;
2. Regulations to be covered in the Audit
3. Checklist.

Audit Schedule Control

This system ensures that all requirements of the audit schedule and plans are achieved and control the day to day operation.

The system is the responsibility of the Auditor and is subject to constant review in order to achieve required goals.

ACA Audit Program

ACA’s Quality Assurance System (QAS) and Compliance Monitoring (CM) audit programs aim is to improve ACA’s by raising the quality and compliance standards of all ACA departments and contract service providers. The QAS / CM audit program compare the performance of all ACA departments and contract service providers by scoring them against the estimated compliance or non-compliance severity table. All ACA departments and contract service providers are expected to attain levels of at least compliance with the compliance or non-compliance severity table. ACA’s QAS / CM audit program are meant to help and encourage all ACA departments and contract service providers to achieve levels of compliance. The non-compliance process describes how the ACA deals with departments and contract service providers that do not achieve compliance.

The Quality Assurance System Audit or Inspection Form QAS-3 contains an Estimated Concern or Non Compliance Severity Values that consists of values of A, B, C, D and E. The Auditor or Inspector will circle that value that, in their judgment, indicates that the area that was audited was found to be compliant or non-compliant. The auditor or inspector will then add the discrepancies that were found and what they believe is the root cause of the discovered non-compliance(s). The audit or inspection will be considered a pass if NO non-compliance(s) are found. The audit or inspection will be considered a fail if any non-compliance(s) are found.

Note: Form QAS-3 will be used for Quality Audits / Inspections and Compliance Audits / Inspections.

The Nominated Person, Department Manager or Supervisor will be notified of passing or failing the audit or inspection. Any ACA departments and contract service providers which fail an audit or inspection to adequately address all non-compliance’s within the agreed upon corrective action and implantation time frame that has been agreed upon by the Quality Assurance Committee.

Note

See Non-Compliant Findings and Quality Assurance Committee Meetings sections for expanded non-compliant findings and corrective actions.

Audit Subject Areas

Typical subject areas for quality audits are:

1. Organization;
2. Plans and Company objectives;
3. Operational Procedures;
4. Operator certification (AOC/Operations specification);
5. Supervision;
6. Aircraft Performance;
7. All Weather Operations
8. Communications and Navigational Equipment and Practices;
9. Mass, Balance and Aircraft Loading;
10. Instruments and Equipment ;
11. Manuals, Logs and Records;
12. Flight and Duty Time Limitations, Rest Requirements, and Scheduling;
13. Aircraft Maintenance / Operations interface
14. Use of MEL;
15. Maintenance Programs;
16. Continued Airworthiness and Part M;
17. Airworthiness Directives management
18. Maintenance Accomplishment;
19. Defect Deferral;
20. Flight Crew;
21. In-Flight Service Representative;
22. Dangerous Goods;
23. Security;
24. Training.

The Audit Process

The Audit will include the following processes:

1. Define the Audit:
   • Audit Objectives
   • Audit Scope
   • Audit Criteria
2. Audit Preparation:
   • Audit Plan;
   • Assign work to audit team;
   • Audit Checklists
   • Opening Meeting
   • Invite Questions
3. Documentation review:
   • Relevant Documents
   • Appropriate requirements
   • AOC Limitations
   • Documentation Hierarchy
4. Notify the Nominated Person, Department Manage or Supervisor of the Audit:
   • Verify Audit Date and Time
   • Set up Entry Meeting
   • Interactive’ Listening
5. Entry Meeting
   • Explain to each person whose department is to be audited the objectives and scope.
6. Data Gathering includes:
   • Making Observations
   • Reviewing Documents, Polices and Procedures
   • Communication Activities
   • Questioning approaches
   • Incorporate Interactive’ Listening
   • Verifying Gathered Data and Information
   • Recording Audit Evidence
   • Write a summary and list all observations and findings
7. Data Analysis:
   • Analyse data with the Head of Quality
   • Raise nonconformities or non-compliant area
   • Classify Findings
8. Closing Meeting:
   • Review positive findings with and observations each person whose department be audited
   • Review non-compliant findings and observations each person whose department be audited
   • Agree upon a corrective action and implementation date for the corrective action

9. Report Findings and give Feedback to Accountable Manager and the Quality Assurance Committee: Report Audit Results

• Review Audit Report Content
• Agree upon Corrective Action(s) for all Non-Compliant Area(s) that were found (if applicable)
• Review Corrective Action for all Non-Compliant Areas that were found (if applicable)
• Closed-Loop Corrective Action Process (if applicable)

10. Follow-up and Closing Meeting with the Person(s) who’s Department was Audited:
    • Review the corrective action(s) with the each person whose department be audited and the corrective actions that have been agreed upon by the Quality Assurance Committee. (if applicable)
    • Observe all areas that were found to be non-compliant
    • Were the Quality Assurance Committees corrective action implemented?
    • Were corrective action(s) effective?
    • Are the non-compliant areas now found to be compliant?
    • Post Closing Meeting Review with the Auditor / Inspector Head of Quality
    • Remit negative follow up Audit or Inspection finding to the Head of Quality
11. Follow Up Audit of Non-Compliant Areas (if applicable)
    • Define the Audit
    • Audit Preparation
    • Documentation review
    • Notify the Nominated Person, Department Manage or Supervisor of the Audit
    • Entry Meeting
    • Data Gathering
    • Data Analysis
    • Closing Meeting
    • Report Feedback and Findings to the Accountable Manager and Quality Assurance Committee
    • Follow-up and Closing Meeting with the Person(s) who’s Department was Audited

The Auditor will brief the Head of Quality as to whether the corrective actions have been implemented and are being followed with a follow up audit.

If corrective actions have not been implemented, the Head of Quality will meet with the Nominated Person responsible for the department to discuss why the corrective actions have not been implemented.

It is the responsibility of the Head of Quality to ensure that all corrective actions have been implemented. The Head of Quality will refer the matter to the Head of Flight Operations if there is a refusal to implement the corrective actions.

Audit Scope

ACA are required, according CAAT requirements to monitor compliance with the procedures that have designed to ensure safe operations, airworthy aircraft and the serviceability of both operational and safety equipment, in doing so ACA will monitor the following using Audits:

1. Organization
2. Plans and Company’s objectives c) Operational Procedures
3. Operator Certification (AOC/Operations Specification)
4. Supervision
5. Aircraft Performance
6. All Weather Operations
7. Communications and Navigations Equipment and Practices j) Mass, Balance and Aircraft Loading
8. Instruments and Equipment
9. Manuals, Logs and Records
10. Flight and Duty Time Limitations, Rest Requirements and Scheduling
11. Aircraft Maintenance/Operations Interface
12. Usage of MEL
13. Maintenance Program and Continuous Airworthiness
14. Airworthiness Directives Management
15. Maintenance Accomplishment
16. Deferred Defect
17. Flight Crew and In-Flight Service Representative
18. Dangerous Goods
19. Security
20. Training

Auditors Requirements When Conducting QAS Audits

A Lead Auditor will be nominated for all Audits that may require more than one Auditor due to the complexity of the Audit. A Lead Auditor will also be assigned to oversee a newly qualified Auditor.

A list of qualified Auditors is kept by the Head of Quality.

Auditors are required to:

1. Perform safety audits as
2. Identify and record any non-conformities and the evidence;
3. Necessary to substantiate such findings;
4. Complete a verbal debrief with the responsible manager. (For line operations this includes the Captain and purser as required);
5. Perform audits with proficiency and professional care and exercise honesty, objectivity and diligences in the performance of their duties and responsibilities.
6. Pass the complete audit paperwork to the Head of Quality within 48 hours;
7. Audit paperwork:
8. Audit record;
9. Non conformities;
10. All supporting documentation including planning detail and check lists.
11. The Auditor is responsible for planning all aspects of the audit in conjunction with the Head of Quality;
12. The Auditor in discussion with the Head of Quality is then responsible for organizing travel arrangements;
13. The team of Auditors will be selected on the basis of experience, familiarity with processes or technology likely to be encountered and to interface effectively with the inspected;
14. In addition the inclusion of trainee Auditors (observers) is to be considered.

The Auditor will allocate sufficient planning time in advance of the audit to ensure that the audit is conducted in accordance with ACA Compliance Monitoring / QAS audit procedures and to achieve the required objectives. The planning time should ideally be one day and conducted on the day prior to the commencement of the audit. However, should longer be considered necessary, then approval is required from the Head of Quality.

Note: If a finding had significant flight safety implications, the Auditor should immediately inform the Auditor, who will inform the Head of Quality.

The Auditors are to ensure that they arrange their audit days, including planning, to be included in their departmental roster.

If there is need for external Auditors, the agreement will be signed between ACA and the Auditor. The relevant procedures and practices applied by ACA will be submitted to the Auditor. External Auditors have to satisfy necessary qualifications for Auditor.

Audit Preparation

When preparing for the audit, it is important to establish the following:

1. Audit plan to include entry and exit meetings;
2. Objectives and scope;
3. Audit staff required;
4. Accommodation requirements;
5. Required documentation;
6. Access to controlled environments.

The following forms are to be used:

1. Non-compliance Report, Form QAS-1;
2. Audit or Inspection Checklist Form QAS-2;
3. Audit or Inspection Form QAS-3;
4. Audit or Inspection Report Form QAS-4.

The Auditor is to ensure that the audit objectives are fully developed before beginning the audit begins.

The Auditor will fully familiarize themselves with the required standards and obtain the required documentation. If no standard exists for a particular area, then familiarization with the existing procedure is required.

Once the Auditor is in possession of required documentation and is fully familiar with the area to be inspected, they allocate the tasks and decide which Auditors are to perform which tasks.

After completing and getting acquainted with the documents, the Head of Quality shall organize a meeting with the Auditor and the Auditors for a short briefing about that particular audit. The date and time of the meeting is set forth in the document naming the Auditor/Auditors, which is delivered to them after the Head of Quality has formed the audit team.

Audit Notification

The Auditor will contact the Nominated Person or the person in charge of the department and inform them of the audit. An Audit Notification Form will be sent to the person in charge of the department. A day and time will be agreed upon to conduct the audit. The Auditor will complete the Audit Notification Forma and place it in the Audit File / Folder.

Audit Entry Meeting

The aim of the meeting is to establish the audit plan, scope, objectives and domestic arrangements. The length of the meeting is determined by the size of the audit, but should not take longer than 15 minutes, particularly as all the pre-audit work will have been completed and involved the audited as appropriate.

Beginning the Audit

Upon the commencement of the audit, an introductory meeting is to be conducted by the Auditor, accompanied by their team, with the audited management (senior management of the area being audited, together with any other pertinent persons).

Techniques Which Contribute to an Effective Audit

Techniques which contribute to an effective audit are:

1. Interviews or discussions with departmental personnel;
2. A review of published documents and CAAT requirements;
3. The examination of an adequate sample of records, documents and logs;
4. The witnessing of processes, activities and procedures which make up the operation;
5. The preservation of documents and the recording of observations.

Data Gathering Guidelines

The conduct of the audit is to include the following considerations.

1. The Auditor is responsible for ensuring the audit achieves the required objectives.
2. Follow the audit plan as closely as possible.
3. Answer all the questions on the primary checklist, Audit or Inspection Checklist Form, QAS-2.
4. The audit may require a variation to the initial audit plan due to unexpected occurrences.
5. Make observations and record all quality concerns and / or non-compliant areas as appropriate on Audit or Inspection Checklist Form, QAS-2 and Audit or Inspection Form, QAS-3.
6. If the audit takes longer than one day, the Auditor is to provide a daily summary of findings to the Nominated Persons, department managers and / or supervisors.
7. The use of “guides” to introduce Auditors to required personnel, locate particular documentation and answer any questions, is generally a normal practice, however, they can be externally valuable as witnesses when nonconformities are identified. The role of the “guides” is to ensure that the Auditors are able to move around freely, are accompanied at all times to meet with company confidentiality and health and safety requirements and to ensure that fair play prevails.
8. Provide positive reactions and comments of findings to the responsible Nominated Persons, managers or supervisors.

Should any other aspects be observed which whilst not being nonconformity could be a cause for concern; these are to be reported immediately to the responsible Nominated Person, department manager or supervisor.

All the findings are to be collected together, utilizing the QAS-2, Audit or Inspection Checklist; QAS-3, Audit or Inspection Form; QAS-4, Audit or Inspection Report.

Reporting Findings

When the audit has concluded the Auditor shall brief the Audited of all findings. Should the Audited refuse to accept the Auditor’s findings, the final decision regarding the validity of a specific finding shall be made by the Quality Assurance Committee.

The Auditor will record and report:

1. The seriousness of the findings;
2. The need for immediate corrective action;
3. The origin of the finding;
4. Initiates procedures to ensure that corrective actions are implemented such that the non-conformity does not recur;
5. A schedule for corrective action;
6. Identify the individual responsible for implementing corrective action;
7. That the corrective action process is correctly implemented and completed;
8. The effectiveness of corrective action through the re audit process;
9. Report any corrective actions that are not being closed within the defined time scale to the Head of Quality;
10. Notifying the Head of Quality in the first instance of any requirement for additional resources;
11. All non-compliance items are reviewed by the Head of Quality for their degree of importance and the allocated time scale for rectification.
12. The Auditor shall submit the QAS-2, Audit or Inspection Checklist; QAS-3, Audit or Inspection Form; QAS-4, Audit or Inspection Report to the Head of Quality within 48 hours.

Data Analysis

Data analysis is a critical component of ACA’s QAS. The Head of Quality and Quality Assurance Committee will review all Non-compliance Forms, QAS-1, Safety Audit Forms and Reports. Tracking and analyzing data is used to enhance our awareness of non-compliant areas within ACA or our contract service providers. This screening and decision process will evaluate the data for significance applied to all incoming data. We collect and analyze safety data as described in this manual and support the sharing of the data to continually improve ACA’s level of overall quality.

This safety information is used to:

1. Identify risks and verify the effectiveness of implemented controls;
2. Identify areas in which safety could be improved;
3. Contribute to accident and incident prevention;
4. Assess the effectiveness of training

Both the Head of Quality and Quality Assurance Committee are responsible for analyzing quality data to identify adverse trends and to identify indicators of potential quality issues.

Over a period of time, this data will help identify indicators that point to potential problems in the system before they occur.

Audit Closing Meeting

An audit closing meeting is held to close the audit. In attendance would be the same personnel as for the audit entry meeting. The Auditor as chairman and supported by their team will provide the inspected with the initial findings of the audit, accompanied by any other relevant comments.

The inspected will be made aware as to the documented process following on from the audit exit meeting; this will ensure that they understand what is required of them in order for the audit process to be completed. The inspected and inspector will agree upon a date that all findings will be corrected.

All reports, forms and logs will be turned into the Head of Quality.

Non-Compliant Findings

Value A or B Non-Compliant Findings

All non compliant finding will be logged on Audit or Inspection Form QAS-3 and the Audit or Inspection Report QAS-4. All non-compliant items will be reviewed by the Auditor and the Head of Quality. The Head of Quality will determine the non-compliant value of each non-compliant process, policy or procedure that was found during the audit. If the non-compliant value is determined to be an A or B, the Head of Quality will immediately notify the Nominated Person that is responsible for the department and immediately stop all department operations. The Nominated Person for the department will enact a temporary new process, policy or procedure with the approval of the Head of Quality. The Nominated Person of the department will be responsible for any temporary revision to all affected manuals and for dissemination of all temporary revisions.

The Head of Quality will call an emergency Quality Assurance Committee meeting. The Quality Assurance Committee will review the non-compliant findings and agree on a new process, policy or procedure for the department. The procedure will be immediately implement the corrective action and is responsible for the revision process for all affected manuals.

Value C, D or E Non-Compliant Findings

The Quality Assurance Committee will review all Value C, D or E non-compliant findings at the scheduled monthly meeting and agree upon any corrective actions that may be required.

Quality Assurance Committee Meetings

Quality Assurance Committee meetings provide organizational control and continual quality improvement are made. The Quality Assurance Committee meeting is a formal meeting of all Nominated Persons and invited department managers, supervisors and Fight Crews. To be effective, a formal Quality Assurance Committee review take place on a regular monthly basis or as an emergency meeting if required.

Input to the Quality Assurance Committee reviews and the process includes the following:

1. Hazard reports;
2. All submitted audit checklist, forms, logs and documents;
3. Non-compliant findings found during audits;
4. Evaluation of processes, policies and procedures;
5. Finding from organizational audits and investigations;
6. Operational feedback;
7. Incidents and near-miss reports;
8. Changes in regulatory policy or civil aviation legislation;
9. Process performance and organizational conformity;
10. Status of corrective and preventative action;
11. Follow up action from previous Quality Assurance Committee reviews;
12. Feedback and recommendations for quality system improvement;
13. Regulatory violations.

Output from the Quality Assurance Committee review process would typically include decisions and actions related to:

1. Improvement of the QAS process throughout the ACA;
2. Agree upon corrective action plan for all found non-compliant areas;
3. Monitor all corrective action plans that have been implemented and ensure that the agreed changes improve ACA’s QAS.

The Quality Assurance Committee meeting that will record the names of all attendees, the minutes of the meeting, a review of all audits, corrective actions to be implemented and other quality topics that are discussed.

Corrective Action

The Head of Quality will:

1. Ensure that the corrective action process is correctly controlled by the Auditor or Auditor and ensure that all corrective actions have been implemented and complied with in the agreed upon timeframe.
2. Monitor the effectiveness of changes resulting from proposals for corrective action identified by the accident and flight safety program.
3. Provide department managers and Nominated Persons with an independent assessment of corrective action, implementation and completion.
4. The Quality Assurance Committee shall provide an independent assessment of corrective action, implementation and completion.
5. Evaluate the effectiveness of corrective action through the follow-up audit process.
6. Highlight any areas of concern to the Accountable Manager including additional resource requirements.
7. Review all non-compliance’s for their degree of importance and the allocated time scale for rectification.

Follow Up Inspections

The Head of Quality will verify that corrective actions have been implemented and are being followed with a follow up inspection.

The following process and procedures will be used for all follow up inspections:

1. Inspection plan to include entry and exit meetings;
2. Objectives and scope;
3. Inspection staff required;
4. Accommodation requirements;
5. Required documentation;
6. Access to controlled environments.

The following forms are to be used:

1. Non-compliance Report, Form QAS-1;
2. Audit or Inspection Checklist Form QAS-2;
3. Audit or Inspection Form QAS-3;
4. Audit or Inspection Report Form QAS-4.

Monitoring and Corrective Action

The principal aim of the Quality Assurance System is to ensure that all defined processes, policies and procedures are being continuously complied with.

Monitoring activity is based on daily monitoring, which is performed by all ACA employees. The organization structure ensures that regulatory compliance is monitored on a continuing basis. In this regard, the aim of the Quality Assurance System is to eliminate the causes of unsatisfactory performance and reduce risk to the lowest possible level.

All failures of implementation of procedures shall be investigated within ACA by the Head of Quality. The appropriate Nominated Persons, department managers and supervisors shall be informed about failures. All data about failures of implementation of procedures as well as information from inspections will be collected and analyzed for the purpose of estimating whether or not quality measures contribute to reducing ACA identified threat and risks

The Head of Quality is responsible for recording all inspection reports, non-conformities, resolutions and recommendations.

The Accountable Manager has ultimate authority for ensuring that sufficient resources are available for the rectification to be effective.

Reports requiring additional financial resources will be brought to the attention of the Accountable Manager during Quality Assurance Committee Meetings.

Closure

Closure of an Inspection with NO Non-Compliant Findings

The Inspection process will be considered closed if there were no non-compliant findings.

Closure of an Inspection with Non-Compliant Findings

The inspection findings will be considered closed when the corrective action has been implemented and has been found to improve quality of the process, policy or procedure in the follow up inspection. All revisions to all affected manuals will be the responsibility of the Nominated Person overseeing the department.