Advisory Circular
Subject: AIR CARRIER INTERNAL
EVALUATION PROGRAMS Date: 4/17/06 Initiated by: AFS-230 AC No: 120-59A
1. PURPOSE.
a. This advisory circular (AC) provides information and guidance material that may be used by air carrier certificate holders operating under Title 14 of the Code of Federal Regulations (14 CFR) parts 121 and 135, to design, develop and implement an Internal Evaluation Program (IEP). The procedures and practices outlined in this AC can be applied to all of an air carrier’s operations.
b. There is no regulatory requirement for an IEP; however, the Federal Aviation Administration (FAA) encourages such a program to increase the awareness of management and all employees of their responsibility to promote continual compliance with all regulatory requirements and best safety practices. Establishing the type of program described in this document is completely voluntary. However, the requirement to have an IEP may be necessary under some other programs such as: Department of Defense’s (DOD) Commercial Air Carrier Quality and Safety Requirements; and International Air Transport Association’s (IATA) Operational Safety Audit (IOSA). Although not a regulatory requirement, a robust IEP can facilitate documentation of air carrier system safety management and quality assurance activities, including but not limited to, the FAA’s Air Transportation Oversight System (ATOS).
Implementation of an IEP as outlined in this guidance material will assist the air carrier in meeting such requirements.
2. CANCELLATION. This AC cancels AC 120-59, Air Carrier Internal Evaluation Programs, dated October 26, 1992.
3. DEFINITIONS.
a. ATOS. A standardized, systems approach to FAA surveillance and certification that provides aviation safety inspectors (ASI) the tools to identify safety trends (management system weaknesses) to spot and correct problems at their root cause before an incident occurs.
b. Audit. An audit is a methodical, planned review which builds on the principles of inspection and is used to determine how business is being conducted and compares results with how business should have been conducted in accordance with established procedures. The most
Page 2 Par 3 frequently used audit categories are (quality) system audits, service/product audits, and process audits.
c. Auditor. An individual who has satisfied defined experience prerequisites and is successfully qualified under a defined training program to conduct audits.
d. Audit Scope. The operational disciplines and/or operational areas that are assessed during the conduct of an audit.
e. Authority. A person or group with the power to command, determine, influence, or judge.
f. Concern. A conclusion by an auditor, supported by objective evidence, which is seen as a potential problem, trend, or inefficiency that may become a finding.
g. Continual: A close prolonged succession or recurrence, infinite in time, without interruption.
h. Control: Key procedure, responsibility, or decisionmaking position within an organization, department, division, or functional area. Checks and restraints are designed into a process to ensure a desired result. Comprehensive evaluations (system audits) will focus on verifying and testing the controls within the organization.
i. Corrective Action. The action(s) taken to correct a deficiency with the intent to preclude recurrence of the finding or non-compliance of an approved standard.
j. Corrective Action Plan (CAP). The total plan of a certificate holder to close all findings through implementation of comprehensive corrective action. This plan should include the changes in policy and/or procedures that will ensure continued compliance.
k. Evaluation. A functionally independent review of company policies, procedures, and systems. If accomplished by the company itself, the evaluation should be done by an element of the company other than the one performing the function being evaluated. The evaluation process builds on the concepts of audit and inspection. An evaluation is an anticipatory process, and is designed to identify and correct potential findings before they occur. An evaluation is synonymous with the term systems audit.
l. Evaluation Standard. Specific criteria on which basis a functional area will be evaluated in terms of compliance or conformance.
m. Evidence. A documented statement of fact, prepared by an air carrier, which may be quantitative or qualitative and is based on observations, inspections, measurements, or tests that can be verified. For the purpose of internal evaluation, evidence should generally be in the form of written documentation that supports an IEP’s analysis and review. These data are necessary to substantiate findings or concerns and to enable management or evaluators to determine the root causes of any reported findings.
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n. Finding. A determination as a result of an audit that compliance or conformance with an evaluation standard is not being achieved.
o. Followup. A process involving monitoring of CAPs to verify timely and effective implementation designed to eliminate the underlying (root) cause of the deficiency.
p. Inspection. The act of observing a particular event or action to ensure that correct procedures and requirements are followed during the accomplishment of that event or action.
The primary purpose of an inspection is to verify that established standards are followed during an observed event or action.
NOTE: The term “inspection” is defi ned in this AC within the context of quality auditing principles. It does not address or define FAA inspections.
q. IOSA. An abbreviation and acronym for IATA Operational Safety Audit, which is an internationally recognized evaluation system designed to assess the operational management and control systems of an operator.
r. Policy. A high-level overall plan embracing the general goals and acceptable practices of a group. Policies state how goals will be achieved.
s. Procedures. A method for accomplishing a process, or for performing an activity.
t. Process. A set of interrelated resources and activities that transform inputs to outputs.
Resources may include personnel, finance, facilities, equipment, techniques, and methods.
u. Process Audit. A documented activity that assesses the effectiveness and efficiency of a series of related or sequential work activities.
v. Quality Assurance. The independent activity of providing the evidence needed to establish confidence, among all concerned, that the quality function is being performed effectively. This activity “assures quality” through independent evaluation of established processes, procedures, and documentation.
w. Quality Control. The determination of the quality of a product by inspection and testing to determine compliance with standards. This activity “controls quality” through establishment of effective controls, documentation, and procedures within specific functional areas.
x. Quality Management System. A defined organizational structure, written management responsibilities, and associated system of processes, procedures, and detail documents to ensure compliance with internal standards or regulatory requirements.
y. Quality System Audit. A documented activity performed to verify by examination and evaluation of objective evidence that applicable elements of the quality management system are documented and effectively implemented in accordance with specific requirements.
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z. Responsibility. The quality, state, or fact of being accountable.
aa. Root Cause Analysis. Determination of what caused a finding. The identification of the root cause is the key to the implementation of an effective corrective action. Items to consider when determining the root cause should include deficiencies in training, materials, procedures, empowerment, or management oversight.
bb. Safety Attribute Inspection. A surveillance tool planned for at the subsystem level and conducted at the “element” level by a team of inspectors to determine if an air carrier has the safety attributes of (1) responsibility, (2) authority, (3) procedures, (4) controls, (5) process measurement, and (6) interfaces adequately designed into their system element process.
cc. Senior Management. The highest level of management within an organization that has the authority and responsibility for setting policy, demonstrating commitment, meeting requirements, approving resources, setting objectives, implementing processes, and achieving desired outcomes.
dd. Service/Product Audit. An objective and structured assessment of conformance to required service level or product level performance characteristics. It may be qualitative or quantitative, as appropriate.
4. RELATED READING MATERIAL. For certificate holders seeking additional guidance on internal evaluation techniques and procedures, an Air Carrier Internal Evaluation – Model Program Guide is available through the National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161; telephone: (703) 487-4600; http://www.ntis.gov. Information on other programs that are related to a carrier’s IEP may be obtained at the following Web sites (see paragraph 6j, which explains how these programs relate to IEP):
a. ATOS: http://www.faa.gov/safety/programs_initiatives/oversight/atos/
b. IATA/IOSA: http://www.iata.org/ps/services/iosa
c. DOD: http://public.amc.af.mil/Business/a34b/
5. BACKGROUND.
a. Operational safety is the responsibility of the certificate holder with the FAA providing regulatory oversight. The certificate holder is expected to have processes, procedures, and documentation in place to ensure regulatory compliance. Additionally, it is to the advantage of every certificate holder to have an effective management system in place to ensure positive control of all operational activities. An IEP is a fundamental element to ensure compliance with external regulatory requirements, identify nonconformance to internal company policies and procedures, and identify opportunities to improve organizational policies, procedures, and processes.
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b. Within the international aviation community, the IEP is also synonymous with the quality assurance function. Quality assurance programs are being expanded beyond aircraft maintenance and engineering to include assessment of all operational functions in terms of regulatory compliance, and conformance to internal policies and procedures, to include evaluation of existing processes, procedures, and documentation. On a broader scale, several nations have published Safety Management System (SMS) guidelines in which the quality assurance (or IEP) function is a fundamental element of the overall management system that includes organizational management, documentation, safety programs, quality assurance, and emergency response planning. The thrust of such initiatives is to effectively integrate these functions into the management system.
c. As a matter of policy, the FAA encourages certificate holders to identify, correct, and disclose instances of regulatory noncompliance. Therefore, the development and implementation of an IEP will benefit both the certificate holder and the flying public.
6. IEP ELEMENTS. An IEP is a high level voluntary program that provides the certificate holder with a means to maintain and refine the management system by continually monitoring the effectiveness and efficiency of processes and systems. The certificate holder applies various assessment and evaluation tools to derive information reporting how the management systems and key processes are meeting both internal quality and external regulatory standards. The program is based on the premise that the certificate holder will design and maintain an IEP that contains fundamental elements of quality and safety. An effective IEP should include the following fundamental elements.
a. Systems-Oriented Process. Internal evaluation should be a continual process that incorporates the techniques of inspections, audits, and evaluations to assess the adequacy of managerial controls and processes in critical systems and to continuously improve those systems based upon the results of regular evaluations. It should also include continuous monitoring and feedback of information on critical processes, and regular trend analysis of resulting data.
b. Beyond Regulatory Compliance. Internal evaluations should extend beyond regulatory compliance to determine the causes of deficiencies and detect and implement needed enhancements to company operating practices before deficiencies occur.
c. Independent. An IEP is an independent process that organizationally has straight-line reporting responsibility to senior management.
d. Defined Responsibility and Authority. The certificate holder’s IEP should identify a person or group within the company who have the responsibility and authority to:
(1) Establish and modify the IEP.
(2) Perform evaluations, audits, inspections, and analysis of data as a part of an ongoing IEP.
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(3) Initiate, recommend, or provide corrective actions, including preventative action through designated reporting channels to address IEP audit findings.
(4) Track and verify the implementation of corrective actions within specified timeframes.
(5) Communicate and coordinate activities with FAA personnel on a regular basis.
NOTE 1: With regard to the princi pals’ independence and authority, reporting lines are important. In some cases, internal evaluation activities may be centrally controlled under the leadership of a corporate quality assurance manager. In other cases, quality assurance managers may be embedded within the operational functi ons reporting to a respective senior manager
NOTE 2: The IEP description (plan/manual) should include an organizational diagram that depicts the independence of personnel who supervise and perform internal evaluati on functions. This diagram should delineate the organizational chain of authority through which IEP audit results are communicated to senior management.
e. Senior Management Review. Senior management involvement in an IEP is crucial to program success. An effective program should include periodic senior management review of IEP audit results.
(1) For the purposes of this program, senior management includes the certificate holder’s chief executive officer, president, chief operating officer, or an equivalent position that has the authority for action to resolve issues.
(2) The management review should be accomplished on a regular basis appropriate to the scope of the IEP, but no less frequently than at least annually. The purpose is to review current performance and opportunities for improvement in an open discussion format to foster idea generation. An agenda should be prepared and distributed to participants at least 1 week prior to the meeting. As a minimum, the agenda should include:
(a) Follow-up actions from previous management reviews, to include progress reports on the status of previously established improvement objectives.
(b) A report on significant or systemic deficiencies, with associated status reports detailing corrective actions and planned follow-up activities.
(c) Strategic or operational changes that could affect the IEP.
(d) Establishment of new or revised objectives.
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(e) Recommendations for improvement and required resources.
(3) Management reviews should be documented to include not only the content, but the resulting management directed action items, if any. A fundamental tenet of the IEP is that senior management is accountable for acting on the information it receives from the program.
The IEP should include assessment of the effectiveness of the management review process and identify opportunities for improvement.
f. Feedback Loop. Quality control takes place by use of a feedback loop. Feedback is a dynamic process whereby output of a system is passed (fed back) to the input to continually achieve the desired results. Often, this is done intentionally to control the behavior of the system. The use of feedback to continually monitor the divergence between objectives and outcomes while implementing changes to reduce the variance is also known as a closed-loop.
An IEP should be designed to achieve quality control through closed-loop feedback.
(1) An effective IEP provides quality-related information to the affected employee group and associated management team members. In addition, information derived from IEP should also be fed back into the operating departments from which the data was obtained. Effective corrective actions that were driven by root-cause analysis of findings may have applicability in other areas of the air carrier. Therefore, opportunities for improvement across the various departments within the air carrier may exist.
(2) Quality-related information is similar to safety-related information typically provided to employee groups via a variety of channels. Feedback may include the sharing of best practices, typical system/process weaknesses, common management errors, etc.. Such information may be disseminated via less formal channels, such as employee “Read and Sign” files, bulletins, newsletters, or Web sites, or it may be incorporated in structural changes, such as program/policy changes, enhancements to training, manual revisions, procedural changes, or personnel reorganization.
(3) The method of feedback should be in accordance with the size and sophistication of the air carrier. The process for this feedback loop should be defined in the IEP documentation.
g. Continual Process. To effectively anticipate problem areas and correct them before actual findings occur, an IEP should be a continual, ongoing process. An internal evaluation should be more than spot-check inspections of operating practices. Stand-alone, spot-check inspections do little more than identify symptoms of potential problems. A continual process is needed to verify whether findings are isolated instances or actual symptoms of systemic policy, process, or procedural problems. An IEP should involve more than planned evaluations, tracking corrective actions, follow-up evaluations, and special evaluations based on identification of trends. It should also include ongoing data collection and analysis to identify opportunities for preventative action to preclude adverse events before they occur. Having a well-structured program ensures that all areas of operations are assessed at appropriate intervals. It also institutionalizes the process so that a change in personnel does not adversely affect the program.
A continuous process is equally important, however, to identify problems that may otherwise be missed by periodic audits. Where appropriate, a continuing process of data collection and
Page 8 Par 6 analysis can enhance the efficiency of the IEP by reducing the need for periodic audits, enabling a data-driven determination of when audits are needed, or providing the information needed to validate the effectiveness of corrective action previously initiated.
h. FAA Interface.
(1) Program Assistance. The FAA does not approve or accept an IEP. An air carrier certificate holder operating under 14 CFR parts 121 and 135 that develops an IEP may ask for assistance from their Certificate Holding District Office (CHDO) or principal inspector (PI).
Preparing program documentation, as discussed in paragraph 7, will provide the FAA with an opportunity to review the proposed duties, responsibilities, procedures, and organization of the certificate holder’s IEP. In all cases that involve IEP development, the FAA will be available to provide advice, assistance, or direction to interested certificate holders.
(2) Sharing Reports. The FAA encourages certificate holders to openly share the results of their IEP with their CHDO or PI. Recognizing that much of the information contained in IEP reports/records could be proprietary, an air carrier should maintain and secure these reports/records on their premises. If given to the FAA, proprietary information will be protected by the FAA in accordance with applicable laws and regulations. Sharing IEP information with the FAA at the air carrier offices can enhance the working relationship between the FAA and the air carrier. Information not required by regulation that remains on the air carrier’s property would not normally be subject to public disclosure.
(3) Disclosure of Findings to the FAA. For certificate holders electing to voluntarily disclose apparent violations discovered by an IEP, further information is provided in AC 00-58, Voluntary Disclosure Reporting Program, current edition. Under this policy, when an air carrier finds a potential violation of the regulations, reports it to the FAA, and meets other specific conditions, the FAA enforcement will be limited to administrative action (e.g., a letter of correction). Disclosures such as these require CAPs designed to eliminate the underlying cause of the problem. Even though the internal evaluation process supports voluntary disclosures, it is not necessary to have an IEP to participate in the voluntary disclosure program, nor is it mandatory to disclose findings discovered during an internal evaluation. However, regulatory violations that are not disclosed but are otherwise discovered by the FAA may subject the air carrier to enforcement action.
i. External Review. It is recommended that an external and independent review be done on the air carrier’s IEP to assess the effectiveness of the program.
j. IEP Relationship to Other Programs.
(1) ATOS. ATOS establishes a standardized systems approach to FAA surveillance and certification, which provides ASIs with the tools to plan, collect data, and assess risks. ATOS tools are designed to examine the systems in place at the air carrier and assess the extent to which they are operating effectively to achieve their intended results. The characteristics of critical system safety processes that are the subjects of ATOS element evaluations are called attributes, and these are used for evaluation and measurement purposes. The ATOS system
Par 6 Page 9 safety attributes are responsibility, authority, procedures, controls, process measures, and interfaces. The objectives of ATOS are to ensure that the carrier has a robust system in place (design evaluation), validate that the system is being operated as designed, and that the desired results are being achieved (performance assessment). The attributes are used in evaluating and measuring these objectives. Although ATOS and IEP are not directly interrelated, the tools used by ASIs to conduct ATOS oversight provide standards that may aid in developing an effective internal evaluation system.
(2) IATA/IOSA Program. Since 2001, IATA has led the effort among the world’s leading airlines, regulatory authorities, and other industry participants to develop a standardized audit program based on internationally recognized standards called IOSA. The IOSA is an internationally recognized and accepted system designed to assess the operational management and control systems of an airline. The system employs internationally recognized quality audit principles conducted in a standardized manner. Audit standards are identified in the IOSA Standards Manual (ISM) and specific audit processes are described in the IOSA Program Manual (IPM). The IOSA and IEP have no direct interface. However, the IOSA standards are internationally recognized and may be used in the development and implementation of an effective internal evaluation system.
(3) Department of Defense (DOD) Program. DOD Directive 4500.53, Department of Defense Commercial Air Transportation Quality and Safety Review Program, charges the Commander-in-Chief (CINC), United States Transportation Command, with ensuring the establishment of safety requirements and criteria for evaluating civil air carriers and operators providing air transportation and operational support services to the DOD. It also charges the CINC with ensuring the establishment of a Commercial Airlift Review Board (CARB) and providing policy guidance and direction for its operation. Title 32 CFR part 861, Department of Defense Commercial Air Transportation Quality and Safety Review Program, establishes DOD quality and safety criteria for air carriers providing or seeking to provide air transportation and, at the discretion of the CARB or higher authority, operational support services to the DOD.
Part 861 also includes the operating procedures of the CARB. The CARB has the authority to suspend air carriers from DOD use or take other actions when issues of air carrier quality and air safety arise. Under the DOD program, civil air carriers and operators providing air transportation and operational support services must have an IEP acceptable to the DOD.
(4) Continuing Analysis and Surveillance System (CASS). CASS is a quality management system for air carriers and commercial operators that monitors and analyzes the performance and effectiveness of airworthiness inspection and maintenance programs. A CASS is required for certain types of air carriers and commercial operators under 14 CFR part 121, section 121.373, and part 135, section 135.431 (for operators subject to section 135.411(a)(2).
(a) As required by regulation, a CASS monitors an operator’s inspection and maintenance programs for compliance with applicable requirements, including FAA regulations and manufacturer instructions. Each certificate holder subject to these regulations is required to establish and maintain a system for the continuing analysis and surveillance of the performance and effectiveness of its inspection program and the program covering other maintenance, preventive maintenance, and alterations and for the correction of any deficiency in those
Page 10 Par 6 programs, regardless of whether those programs are carried out by the certificate holder or by another person.
(b) FAA guidance on CASS is available in AC 120-79, Developing and Implementing a Continuing Analysis and Surveillance System, current edition. As noted therein, an IEP is an independent program intended to provide information to senior management as to how well critical programs, such as a CASS, are working. An IEP is not a substitute for CASS.
An IEP poses questions necessary to determine if the operator’s systems, such as CASS, are effective and efficient, and if there are opportunities for improvement in those systems.
However, much of the guidance provided in AC 120-79 for CASS, such as its discussion of root cause analysis, risk assessment, data management, and data analysis, is equally applicable to an effective IEP.
(5) Safety Program. A safety program and an IEP are complimentary functions within the management system. Both provide top management feedback regarding the health and effectiveness of the organization as a whole.
(a) Safety programs include the capture and analysis of employee safety/hazard reports, the investigation of operational incidents and accidents, the oversight of risk assessment activities, and flight operations data assessment programs. As commonly practiced, safety programs are often reactive in nature in that they involve analysis of events that have already occurred (i.e., investigative efforts are oriented to identify root cause and establish corrective actions to prevent reoccurrence or limit frequency to acceptable risk levels).
(b) In contrast, quality programs (or IEP) are designed to systematically and proactively search for weaknesses in the management system, operational processes/procedures, or documentation. An effective IEP seeks to assure that key processes and controls are in place across the full spectrum of operational safety. The IEP is focused on verifying organizational compliance with all external regulatory requirements and internal organizational policies and procedures. These comprehensive system audits identify opportunities for improvement, which ultimately enhance safety through establishment of predictable and reliable business processes.
7. IEP DESCRIPTION. Air carrier certificate holders operating under parts 121 and 135 that are interested in developing an IEP are encouraged to define and document the following essential elements in the program:
a. Program Documentation. It is recommended that IEP procedures and responsibilities be documented. This paragraph provides suggestions for preparing and structuring program documentation.
(1) Preparing Program Documentation.
(a) Preparing a documented program is a recommended practice for the certificate holder. Certificate holders should review the size and complexity of their operation to determine appropriate level of documentation.
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(b) Program documentation should describe the duties, responsibilities, procedures, and organization of a certificate holder’s IEP.
(c) Copies of the program documentation should be distributed to appropriate company personnel, so they are aware of, and are familiar with, IEP procedures. In addition, revisions should be made as necessary to ensure that the program documentation continues to reflect the certificate holder’s current internal evaluation procedures and organization.
(2) Structuring Program Documentation. As an example, a sample program manual using the program elements discussed in this AC is provided in the Appendix. The number of items addressed and how they are documented will ultimately depend on the size and complexity of each certificate holder’s operation.
b. IEP Scope. Consideration needs to be given to defining the scope of the program. For example, the carrier may include the following areas: organizational management, flight operations and dispatch, station operations, onboard service, aircraft maintenance, security, and ground handling. It is recommended that any business area within the organization that affects the integrity of the carrier should be considered.
c. Evaluation Standards. Each certificate holder should identify and communicate a specific standard(s) against which each functional area will be evaluated. Each such documented standard should be developed with the assistance of the applicable management personnel. Once established, such standards must be clearly communicated and understood by the management team. A specific internal standard may be developed as a composite of multiple sources including, but not limited to:
(1) External regulations (Title 14 CFR, OSHA, etc.).
(2) Internal company operating policies and procedures.
(3) IOSA Standards and Recommended Practices (ISARP).
(4) DOD Quality and Safety Requirements (QSR).
(5) International Civil Aviation Organization (ICAO) requirements.
(6) ISO 9001:2000 management elements (as amended).
d. Types of Evaluations.
(1) Planned Evaluations. An effective program will establish a schedule of events that will be performed during a set calendar period under the IEP. It is helpful to divide the complete schedule into segments that are practical from a workload standpoint. However, it is important to schedule evaluations to allow enough flexibility for resources to be committed to special evaluations or followup evaluations, if needed.
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(2) Special Evaluations. Conduct special evaluations based on concerns or priorities set by senior management. The need for special evaluations can be driven by such factors as a review of industry trends, FAA concerns, or adverse trends identified by the IEP or other internal programs.
(3) Follow-up Evaluations. Schedule and conduct followup evaluations to ensure that corrective action commitments were met and to verify that corrective actions were effective.
e. Evaluation Schedule. It is essential for an air carrier’s IEP to include a defined schedule of planned activities. This schedule serves to verify that the IEP is comprehensive, well controlled, and timely. A published schedule also provides a vehicle for keeping management informed. An internal evaluation schedule should include a planned cycle for periodically reviewing areas to be covered by the certificate holder’s IEP. The evaluation cycle can be flexible but should not exceed 3 years. The scheduling process should also be dynamic and allow for special evaluations when trends are identified. In addition, followup evaluations should be scheduled as necessary to verify that corrective action commitments were met and that they were effective in eliminating any reported findings.
f. Corrective Action and Follow-up. An IEP should include procedures that ensure that CAPs are developed in response to findings and to verify their timely and effective implementation. Internal evaluation personnel may participate in the development of a CAP and should review the plan prior to implementation. However, organizational responsibility and accountability for the development and implementation of CAPs should reside with the operational departments cited in the finding.
(1) A CAP should include:
(a) A detailed description of the finding and how it was discovered. This should include discussion of the scope and extent of the problem so that candidate solutions can be analyzed properly.
(b) Analysis of evidence to determine the root cause(s) of the finding. Root cause analysis treats errors as defects in the system rather than in a person. Root cause analysis looks beyond the symptom to find the organizational defect that permitted an error to occur. Its goal is to correct the fundamental problem and to prevent recurrence. The more thorough the analysis, the greater the likelihood the operator will uncover why the system deficiency occurred and how the organization can respond effectively.
(c) Identification of planned corrective actions to be taken in response to the finding to include specification of how, when, and where these actions will be taken.
(d) Implementation schedule, including a timeframe for putting corrective actions in place.