Appendix 2 Determination of Corrective Action Options Responsibility Director of QA designates corrective action team, led by primary affected technical department(s), whose manager(s) designates a team leader.
Procedures Risk assessment of the problem and the options. The CASS auditor/analyst or reliability group representative does not propose corrective actions but reviews possibilities for systems considerations and relevance to RCA.
Flow Team presents recommendation to CASS board.
Selection of Corrective Action and Corrective Action Plan Responsibility Director of QA.
Procedures Decision based on a priority for safety and regulatory compliance. Risk assessment is the basic tool to support the decision. CASS board verifies systems considerations and relevance to RCA.
Flow Depends on the level of the problem and the corrective action. Routine issues may be resolved at the team level with direct implementation by the affected area manager; advise the CASS board of this action. More significant program changes may require prior review and concurrence from CASS board or elevation to vice president of engineering and maintenance.
Followup Responsibility CASS board.
Procedures CASS auditor/analyst or reliability group, as applicable, assigned to develop a followup plan based on the seriousness of the problem.
Followup may include communications from a technical area verifying implementation, followup audits or data collection, and/or followup evaluation.
Flow Technical area manager reports to director of QA, who reports to CASS board.
NOTE: The above tables provide many examples of the system safety attributes: controls and procedures.
Appendix 2
l. Communications Between CASS and Other Personnel (A System Safety Attribute:
Interfaces).
Communication of Specific CASS Results and Actions Responsibility CASS board.
Procedures Audits based on updated checklists. Operational data are collected and stored in computerized database systems; some analysis and alerting features are automated. Audit and analysis results communicated through paper forms. Corrective action tracking through computerized database system.
Flow Through electronic mail communications and standard paper reports, information flows among CASS board, corrective action teams, technical areas, and the director of QA.
Communications with Maintenance Personnel Responsibility CASS board.
Procedures CASS training included for all personnel. Initial and recurrent training.
The certificate holder’s employee newsletter includes a brief monthly report on CASS results.
Flow CASS board works with training and company communications department, and receives feedback from managers and supervisors, particularly in maintenance areas.
Appendix 2 Interfaces (A System Safety Attribute: Interfaces) Responsibility CASS board.
Procedures Reliability group provides regular reports on analysis results, trends, and concerns regarding operational data.
Auditors/analysts provide regular reports on findings, analyses, trends, and concerns.
VDRP manager provides summaries of disclosures and proposed comprehensive fixes for CASS review and input.
To CASS Board Designated CASS auditor/analyst reviews reports and at least annually reviews maintenance-related Aviation Safety Reporting Program reports for consideration in setting audit and operational data collection priorities.
Feedback to technical areas regarding findings, trends, concerns and followup results.
Feedback to VDRP manager regarding proposed comprehensive fixes;
coordination with director of QA.
Monthly reliability analysis summaries and CASS summaries for distribution to vice president of engineering and maintenance; director of QA and other senior management; department managers in maintenance, flight and ground operations, IEP, and safety office; and FAA principal inspector (PI).
CASS reports reflect VDRP comprehensive fixes without detailing the initiating circumstances.
Copies of reliability reports and CASS summaries to FAA PI.
CASS board meeting minutes.
From CASS Board Semiannual summary report to CEO; copy to FAA PI.
Flow Communications channeled through director of QA.
m. Personnel Who Perform CASS Functions.
(1) Full-time auditors and analysts; in some cases, an auditor may also be an analyst.
(2) All members of the CASS board who have not participated in specific CASS training receive a total of 12 hours initial training covering CASS, root cause and systems analysis, and human factors.
How the Certificate holder Evaluates Its CASS (A System Safety Attribute — Process Measurement) Responsibility Vice president of engineering and maintenance.
Procedures IEP evaluates CASS annually.
Flow The CASS transmits IEP reports on CASS directly to the CEO and to the vice president of engineering and maintenance.
Appendix 3 APPENDIX 3. SAMPLE CASS FOR A SMALL CERTIFICATE HOLDER Type of Certificate Holder Fleet composition Two turbojet airplanes; Gulfstream G-III (12 seats).
Number of maintenance base and line stations Base station only.
Proportion of maintenance contracted to third parties A checks in-house; B, C, and D checks, all off-wing engine maintenance and all overhauls of engines, instruments, and avionics contracted out.
Scheduled or on-demand On-demand (Title 14 of the Code of Federal Regulations (14 CFR) part 135).
Size and structure of the maintenance organizations Maintenance organizational structure comprises of the Director of Maintenance (DOM) with chief inspector.
a. Continuing Analysis and Surveillance System (CASS) Management and Planning.
b. General Priority. This certificate holder prioritizes in the following general manner:
(1) Safe operations (air and ground).
(2) Detect and prevent noncompliance.
(3) Improve operating efficiency.
c. CASS Written Procedures (A System Safety Attribute: Procedures). CASS chapter in general maintenance manual. The CASS chapter includes specific procedures for root cause and systems analysis, and discussion of awareness of human factors.
d. CASS in the Certificate Holder Organization. Chief executive officer (CEO) actively participates in the CASS. CASS specifically appears on functional organizational flowchart.
e. Authority for CASS (A System Safety Attribute: Authority). The DOM (14 CFR part 119, § 119.65 DOM) has overall authority and responsibility for this air carrier’s maintenance program, including the CASS.
f. Responsibility for CASS (A System Safety Attribute: Responsibility). DOM heads CASS committee, which includes the CEO, chief inspector, and director of flight operations.
g. Policy for CASS Auditor/Analyst Independence from Production (A System Safety Attribute: Controls). DOM “borrows” auditors from within or outside the company based on auditor qualifications. Priorities are (1) independence from audited department and (2) experience or familiarity with the area to be audited. Every 5 years the company contracts an independent firm to conduct an outside evaluation of CASS and other certificate holder systems and programs to verify sufficient objectivity in the audits.
h. Policy Regarding Personnel Actions Resulting from CASS Findings/Results. Inadvertent errors will not lead to disciplinary action. Full reporting and disclosure encouraged to facilitate system corrections.
Appendix 3
i. Surveillance and Analysis of Performance of Maintenance Program.
Audits Responsibility DOM.
Prioritization CASS committee assigns priorities based on risk assessment.
Cycles The CASS committee establishes an audit plan and accomplishes onsite audits annually, depending on the risk assessment. Also depending on the risk assessment, some areas never receive an onsite audit assignment.
Scope All internal and third-party areas of maintenance.
Process CASS committee developed audit checklists for use by auditors, who may be committee members or personnel drawn from throughout the company. DOM receives reports of all maintenance-related events such as rejected takeoffs for analysis and use in risk assessment for audits.
Schedule special audits as needed. Vendors conduct their audits by document reviews, written questionnaires, and telephone followup, or combinations of these. Regulations require followup if preliminary results raise concerns.
Flow Initial results are reported to the DOM.
Analysis Responsibility DOM (conducts preliminary analysis with the auditor).
Perform preliminary root cause analysis Auditor/analyst.
Classify hazards/ perform risk assessment CASS committee.
Flow CASS committee reviews all findings/initial analysis and details of issues as deemed necessary by the DOM. The CASS committee acts as the core corrective action team (as required, other personnel may supplement this).
Appendix 3
j. Surveillance and Analysis of Effectiveness of Maintenance Program.
Operational Data Collection Responsibility DOM.
Prioritization DOM.
Scope Basic. Includes pilot reports, Engine Condition Monitoring (ECM), mechanical delays, cancellations, teardown reports, and other data.
Process Data collection oriented toward detecting trends, positive or negative, before occurrence of events. The CASS committee formally reviews the list of operational data sets collected every 2 years to determine if it needs to be adjusted. The initial list is based on CASS committee experience at other operations and with this fleet.
Flow Flight operations and DOM transmit reports to CASS committee.
Analysis of Operational Data Responsibility DOM.
Prioritization CASS committee.
Process Analysis performed by DOM or chief inspector. Preliminary determination of possible root causes or possible procedural changes.
Flow Report results to the CASS committee.
Corrective Action Responsibility DOM.
Procedures Designates technical personnel to perform final Root Cause Analysis (RCA) and identify corrective action options. DOM oversees the process and ensures the RCA process, including human factors and systems analysis, is followed.
Use of specific analytical systems Based on DOM’s training and internally developed procedures.
Flow DOM presents corrective action options to CASS committee.
Selection of Corrective Action and Corrective Action Plan Responsibility CASS committee.
Procedures Decision based on a priority for safety and regulatory compliance. Risk assessment is the basic tool to support the decision. CASS committee verifies systems considerations and relevance to RCA.
Flow CASS committee makes selection.
Appendix 3 Followup Responsibility CASS committee.
Procedures Affected technical personnel report to CASS committee on implementation of corrective action. DOM may independently verify.
Followup audit planned for following year cycle of audits.
Flow Technical area reports to DOM, who informs CASS committee.
NOTE: The above tables provide many examples of the system safety attributes: controls and procedures.
k. Communications Between CASS and Other Personnel (A System Safety Attribute:
Interfaces).
Communication Specific CASS Results and Actions Responsibility CASS committee.
Procedures Audits based on updated checklists. The CASS committee collects operational data and stores it in files. Audit and analysis results communicated through electronic mail.
Flow Electronic mail communications to all company management.
Communications with Maintenance Personnel Responsibility CASS committee.
Procedures DOM conducts initial briefing for all personnel to orient them on CASS.
Flow DOM to all affected personnel.
Interfaces (A System Safety Attribute — Interfaces) Responsibility CASS committee.
Procedures DOM provides regular reports on analysis results, trends, and concerns regarding operational data.
To CASS Committee Chief inspector reviews reports at least annually and reviews maintenance-related Aviation Safety Reporting Program reports for consideration in setting audit and operational data collection priorities.
Feedback to technical areas regarding findings, trends, concerns, and followup results.
From CASS Committee CASS committee meeting minutes.
Flow Communications channeled through DOM.
l. Personnel Who Perform CASS Functions. Auditors and analysts are only part-time in these functions. They receive some specific CASS training, including on-the-job and formal training.
Appendix 3 Page 5 (and 6) How the Certificate Holder Evaluates its CASS (A System Safety Attribute: Process Measurement) Responsibility CEO.
Procedures CEO reviews indicators of a properly designed and functioning CASS, including quality of analysis, independence of the audits, and sufficiency of third-party audit procedures.
Flow The CEO documents his or her review and shares it with CASS committee members and the FAA principal inspector (PI).
Appendix 4 APPENDIX 4. CASS MANUAL/DOCUMENT SAMPLE CONTENTS
a. General Information.
(1) Definition of terms.
(2) Purpose of the Continuing Analysis and Surveillance System (CASS).
b. System Organization and Personnel.
(1) CASS organizational chart.
(2) Person/position with authority, including how to determine whether a CASS is functioning properly and policies/procedures for modifying the CASS.
(3) Person/position with responsibility.
(4) Duties and responsibilities of CASS personnel (supervisors, auditors, analysts).
c. Elements Basic to a CASS.
(1) Policies/procedures for scheduling and conducting internal/external audits.
(2) Policies/procedures for identifying and updating the list of operational data sets to be collected, and for collecting data.
(3) Policies/procedures for analyzing audit results.
(4) Policies/procedures for analyzing operational data.
(5) Policies/procedures for developing proposed corrective actions, and analyzing them.
(6) Policies/procedures for approving and implementing corrective actions, including changes to the maintenance program.
(7) Policies/procedures for monitoring and followup of corrective actions.
d. Critical CASS Interfaces.
(1) Policies/procedures for communications within the CASS and between the CASS and other areas of the operation.
(2) Interface documents (audit forms and checklists, corrective action notices, statistical and periodic reports, etc.; including, as applicable, control, storage, retrieval of CASS records and communications).
e. Relationship of the CASS to Other Programs. Policies/procedures to integrate or relate other certificate holder programs to the CASS.
Appendix 4
f. Personnel Qualifications.
(1) Policies/procedures regarding qualifications and training of CASS personnel.
(2) Training records.
Appendix 5 APPENDIX 5. PUBLICATIONS USED TO DEVELOP THIS AC
a. Related Documents (current editions). See http://www.airweb.faa.gov.
• Advisory Circular (AC) 00–46, Aviation Safety Reporting Program.
• AC 00–58, Voluntary Disclosure Reporting Program.
• AC 120–16, Air Carrier Maintenance Programs.
• AC 120–59, Air Carrier Internal Evaluation Programs.
• AC 120–66, Aviation Safety Action Programs (ASAP).
• AC 120–72, Maintenance Resource Management Training.
• AC 120–92, Introduction to Safety Management Systems for Air Operators.
• AC 129–4, Maintenance Programs for U.S.-Registered Aircraft Under 14 CFR Part 129.
• Federal Aviation Administration (FAA) Order 8040.4, Safety Risk Management.
• FAA Order 8900.1, Flight Standards Information System (FSIMS).
b. Other Documents and Information Used to Prepare This AC. In addition to the references cited above, this AC was prepared using the following documents and information:
• Beyond Aviation Human Factors (1995). Daniel E. Maurino, James Reason, Neil Johnson, and Rob B. Lee. Hants, England: Ashgate Publishing Limited.
• Handbook of Airline Operations (2000). Gail F. Butler and Martin R. Keller, editors.
New York: The McGraw-Hill Companies, Inc.
• Handbook of Aviation Human Factors (1999). Daniel J. Garland, John A. Wise, and V.
David Hopkin, editors. Mahwah, NJ: Lawrence Erlbaum Associates, Inc.
• Human Factors and Maintenance Resource Management (March 7, 2002). Presented by Yosef Morgan, Applications Manager, Maricopa County Community College. Phoenix, Arizona.
• Human Factors in Aviation (1998). Edited by Earl L. Wiener and David C. Nagel. San Diego: Academic Press.
• Managing the Risks of Organizational Accidents (1997). James T. Reason. Hants, England: Ashgate Publishing Limited.
Appendix 5
• Risk Management in Aviation (March 7, 2002). Presented by Jim Hein, Federal Aviation Administration Safety Inspector, Honolulu Flight Standards District Office. Phoenix, Arizona.
• The Limits of Safety: Organizations, Accidents, and Nuclear Weapons (1993). Scott Douglas Sagan. Princeton, NJ: Princeton University Press.