ISAGO Q5 AIMS
Auditee Manual
Effective January 2015
4th Edition
NOTICE
DISCLAIMER. The information contained in this
publication is subject to constant review in the light
of changing government requirements and regulations. No subscriber or other reader should act on
the basis of any such information without referring
to applicable laws and regulations and/or without
taking appropriate professional advice. Although every effort has been made to ensure accuracy, the
International Air Transport Association shall not be
held responsible for any loss or damage caused
by errors, omissions, misprints or misinterpretation
of the contents hereof. Furthermore, the International Air Transport Association expressly disclaims
any and all liability to any person or entity, whether
a purchaser of this publication or not, in respect of
anything done or omitted, and the consequences of
anything done or omitted, by any such person or entity in reliance on the contents of this publication.
© International Air Transport Association. All
Rights Reserved. No part of this publication may
be reproduced, recast, reformatted or transmitted in any form by any means, electronic or
mechanical, including photocopying, recording or any information storage and retrieval system, without the prior written permission from:
Senior Vice President
Safety, Operations & Infrastructure
International Air Transport Association
800 Place Victoria
P.O. Box 113
Montreal, Quebec
CANADA H4Z 1M1
ISAGO Q5 AIMS Auditee Manual
ISBN No: 978-92-9252-475-3
© 2015 International Air Transport Association. All rights reserved.
Montreal—Geneva
TABLE OF CONTENTS
Table of Contents
1
INTRODUCTION .............................................................................................................................. 3
1.1 ISAGO Commitment to Quality .............................................................................................................3
1.2 Corrective Action Process ....................................................................................................................4
1.2.1 Corrective Action Plan ................................................................................................. 4
1.2.2 Root Cause (RC) ........................................................................................................... 4
1.2.3 Final Action Required (FAR) ....................................................................................... 5
1.2.4 Final Action Taken (FAT) ............................................................................................. 5
2
ACCESSING THE SYSTEM ............................................................................................................ 7
3
ACCESSING THE CORRECTIVE ACTION RECORDS (CAR) ...................................................... 9
4
EDITING CORRECTIVE ACTION RECORDS .............................................................................. 13
4.1 Saving and/or resetting the information that has been entered ...................................................... 13
4.2 Initiating Info Tab ................................................................................................................................. 14
4.3 Root Cause Tab .................................................................................................................................... 15
4.4 Interim Action Tab................................................................................................................................ 17
4.5 Final Action Tab ................................................................................................................................... 18
4.5.1 Part 1 - Final Action Required Section ..................................................................... 19
4.5.2 Part 2 – Final Action Taken Section ......................................................................... 20
4.5.3 Observations Which Will Not be Actioned by the Auditee .................................... 21
4.6 Review / Close Tabs............................................................................................................................. 23
4.7 Docs Tab ............................................................................................................................................... 23
5
REQUIREMENTS FOR ROOT CAUSES CORRECTIVE ACTIONS ............................................ 25
5.1 Root Cause ........................................................................................................................................... 25
Root Cause : ................................................................................................................................................. 29
5.2 Final Action Required .......................................................................................................................... 29
5.3 Final Action Taken ............................................................................................................................... 30
6
EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS ............................................... 33
6.1 Unsuitable Examples of Corrective Actions ...................................................................................... 47
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Record of revisions
Edition number
Revision Number
Issue date
Effective date
First Edition
Revision 0
October 2008
October 2008
First Edition
Revision 1
June 2009
June 2009
Second Edition
-
September 2010
September 2010
Third Edition
-
June2013
June 2013
Fourth Edition
-
December 2014
January 2015
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INTRODUCTION
1
Introduction
The aim of this user manual is to provide procedures and guidance to assist Ground Service
Providers (GSP) in processing ISAGO corrective actions, to support the program objective of
providing acceptable quality and value in ISAGO corporate and station reports.
The manual contains procedures for using the Q5AIMS electronic audit tool, as well as minimum
requirements for the documenting of corrective actions by the Auditee. Numerous examples of
root causes, final actions required and final actions taken are also included.
This manual is primarily for the use of the Auditee coordinator during audit follow-up, but should
also be distributed to any Heads of Departments who will be providing corrective actions
descriptions to the Audit Organizations (AOs) and/or to the Pool member(s) (PMs).
Note: For the purpose of this manual we will use a general term “auditing entity” for AOs and
PMs.
1.1
ISAGO Commitment to Quality
The detail, accuracy and clarity of the corrective actions record for ISAGO Findings and
Observations is key to providing a clear record of GSP’s actions taken to permanently correct
any audit non-conformities. ISAGO reports are shared with the ISAGO Pool Members, as well
as with Regulatory Authorities, so it is important to keep in mind that ISAGO reports will be
regularly examined by industry reviewers, worldwide.
To maintain this valuable flow of information to the industry, the Quality Assurance Departments
of all the AOs, PMs and IATA are committed to ensuring a consistent level of detail, accuracy
and clarity for all the information contained in ISAGO reports.
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1.2
Corrective Action Process
The general corrective action process for closing Findings and/or Observations is set out below.
Upon receipt of the Corrective Action Record(s) (CAR(s)) from the auditing entity, the Provider shall
deliver a Corrective Action Plan (CAP) to the auditing entity that addresses each finding and/or
observation that includes statements for each Root Cause (RC) and the Final Action Required (RC).
(Note that recording RC in the CAR is mandatory for all non-conformities identified during the on-site
audit.)
The records of the corrective actions taken to close an Audit is the most fundamental source of
information in an ISAGO report and it is vital that the information provides clear, detailed descriptions
of corrective actions taken by the Provider, as well as the evidence reviewed and verified by the
auditing entity.
Industry focus is generally on the nature of the Findings and Observations, the corrective actions
taken by the Provider and if the corrective actions were adequately verified by the auditing entity.
1.2.1
Corrective Action Plan
A Corrective Action Plan (CAP) must be recorded for each Finding or Observation. The Root Cause,
Final Action Required and Date Due fields of the Corrective Action Plan(s) (CAP) in Q5AIMS must be
completed and accepted for all initial audits within 45 days of the on-site Closing meeting. The CAP
shall be completed by the Provider and accepted by the auditing entity.
The CAP for renewal audits shall be developed in such a way that assures that the Final Actions
Taken (FAT) are verified, and CARs are closed by the auditing entity at least 30 days prior to
registration expiry. If the GOPM (Figure 2.2) timelines are followed and the renewal audit is
scheduled 150 days prior the registration expiration date, the Q5AIMS CAP for renewal audits shall
be completed and accepted within 30 days of the on-site Closing meeting. The CAP shall be
completed by the Provider and accepted by the auditing entity.
After the CAPs have been accepted by the auditing entity, the Corrective Action for each Finding (and
Observation, where applicable) must be implemented by the Auditee, within the required timelines, in
accordance with the CAP. During the corrective action process, the status of corrective actions shall
be regularly reported to the auditing entity.
The auditing entity must be notified as soon as the corrective actions for each Finding and/or
Observation (where applicable) are completed. Evidence of corrective action implementation must be
provided to the auditing entity.
The auditing entity will review the evidence and either:
1. Notify the Auditee that the corrective actions have been accepted, and the Finding or
Observation is closed, or
2. Advise that further action is required.
1.2.2
Root Cause (RC)
The RC is very important information and must be completed for all CARs, even if no corrective
action is taken (applicable only to observation). They are documented for the following reasons:
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INTRODUCTION
1. To assist the Provider, when doing internal analysis, of the causes of not conforming with the
operational requirement, and identifying the corrective actions that need to be developed;
2. To facilitate effective long-term statistical analysis by the industry (after de-identification), of
the reasons for all Finding & Observations across the ISAGO program, i.e. seeking patterns
and trends of the causes for the non-conformities of certain operational functions by
Providers.
1.2.3
Final Action Required (FAR)
The objective of the FAR is to provide preliminary information to the auditing entity on the type and
extent of the corrective action to be implemented. The auditing entity will review the FAR and advise
the Provider whether the type and extent of the corrective actions being planned will be appropriate
and adequately comprehensive to close the Finding and/or Observation.
Before submitting the FAR to the auditing entity, the Provider shall verify:
1. that the corrective actions address all aspects of the non-conformity and root cause;
2. that proper English spelling and grammar has been used;
3. the completeness of all required areas of the FAR.
Note: IATA has chosen international English for its new style which consists, among others elements,
of using the “z” as in “organization”.
1.2.4
Final Action Taken (FAT)
The FAT will always be the primary focus of any ISAGO report review by the industry, as these are
the changes and upgrades introduced by the Provider to achieve conformity with ISAGO.
When closing a finding, the auditing entity must evaluate whether a return visit will be needed.
Corrective actions to documentation non-conformities can usually be verified by desk-top exercises,
especially in case verification of implementation is not needed. However, for corrective actions that
are technical and/or involve changes to equipment, should be verified onsite to review the systems,
the checking of operation, management functionalities, etc.,
Should the auditing entity indicate that a second visit is necessary for the purpose of verifying
implementation of final corrective action, the Auditee shall pay the costs associated with the return
inspection, excluding airline ticket costs for travel to and from the GSP’s site. Note that this provision
is applicable only to audits performed by PM,
In case verification of corrective action implementation is done remotely and the evidence to be
reviewed is written in the language that is not understood to the auditing entity, it is GSP’s
responsibility to translate the revised and the associated documentation, related to corrective actions,
into English.
All Findings shall be closed by the auditing entity in accordance with the accepted CAP within six (6)
consecutive months following the date of the on-site Closing Meeting. For renewal audits, all Findings
shall be closed prior expiry date to ensure the final ISAGO audit report (GOAR) is delivered to IATA
30 days prior to the expiry of the registration.
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ACCESSING THE SYSTEM
2
Accessing the System
To gain access to the Q5AIMS server, any computer with an internet connection can be used. No
additional software or components are required, as the system is accessed through a web browser
1
(Internet Explorer, Firefox, Google Chrome …).
All post audit activities are tracked and recorded using the Q5AIMS server. The information entered
is immediately available to anyone involved in the follow up process that has a username and
password.
a)
To access the system go to:
http://www.q5iata.com
b)
The browser will connect to the Q5AIMS server and request the username and
password.
c)
Enter the username and password that have been provided by the auditing entity and
click Sign In.
If the username and/or password are incorrect, the system will deny entry and the login
screen will re-appear, for re-entry of the information. Please contact your auditing entity to
have the username and/or the password verified.
Note: When the user logs into the application for the first time, the home page will be set
to display MY Q5 module by default. The MY Q5 module can be turned on or off under
the settings module. This can be accessed through the Settings tab and then selecting
User Settings.
If MY Q5 is turned off, the screen below will appear.
1
Google Chrome is not recommended to use due to some compatibility issues.
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If the username and password are correct, the list of all Corrective Action Records
(CARs) associated with the Auditee will appear, as in the example below:
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ACCESSING CORRECTIVE ACTIONS RECORDS (CAR)
3
Accessing the Corrective Action Records (CAR)
The submenu contains two tabs titled CARS and Custom. The CARs tab lists all Findings and
Observations associated with the Auditee.
There are two (2) ways to access the CARs:
1. From the home page, if My Q5 is ON,
Each Finding or Observation can be accessed by clicking on the CAR ID.
If at any time, the Auditee is unsure where he/she is in the system or how to continue, the
Home tab should be clicked in order to return to the main menu.
If there are several pages of CARs, click on the page number at the top of the list to move to
the required page.
Once the ID number of the CAR is selected, the system will open up the CAR, as per the
example below.
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As an alternative option to access corrective actions, the following may be completed:
2. From the Actions tab
On the main menu, move the mouse pointer over the Actions tab and a sub-menu will
open up.
From the choices that are presented, select Find/Edit Corrective Action.
The system will display a documentation tree and the audit ID as shown by the Auditee’s
three-letter ISAGO designator should be chosen.
Once the audit ID is selected, the following page will appear:
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ACCESSING CORRECTIVE ACTION RECORDS (CAR)
The All and All option buttons at the top of the page are already preselected.
To see a list of all CARs, click on Find Corrective Action in the bottom left corner.
To view individual CARs, define the search criteria by selecting the Dates, Assigned To, Initiated
By and Type, as appropriate.
The list of CARs will appear and each corrective action can be accessed by clicking anywhere in the
row of a CAR.
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4
Editing Corrective Action Records
The CAR contains the relevant information for each Finding or Observation and is divided into seven
sections – represented by the seven tabs as seen on the webpage:







Initiating Info
Root Cause
Interim Action
Final Action
Review
Close
Docs
The Auditee ONLY completes the three sections in bold font above. These two sections will be
individually addressed in the following chapters.
4.1
Saving and/or resetting the information that has been entered
At the bottom of the CAR record, the three of the four buttons as seen below are used to save or
reset information that has been entered.

If changes have been made but are not to be kept, click on Reset.

To go back to the list of CARs, click on Back.

To save changes, click on Save.
Note: The Escalation Notification button is not currently used.
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4.2
Initiating Info Tab
The Initiating Info section contains general information on the non-conformity such as type, level,
who initiated it and the original auditor comment from the checklist.
This section is read-only and no modifications can or need to be made. The information is
completed by the auditing entity.
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EDITING CORRECTIVE ACTION RECORDS (CAR)
4.3
Root Cause Tab
The Root Cause section (Tree View) must be completed by the Provider for each Finding and
Observation, regardless of whether corrective action is being taken or not (for Observations). This
information is vital to assist the Auditee in identifying the background reasons for the lack of a
process, procedure, etc. and for long-term analysis (after de-identification) of ISAGO Program
trends.
In this section, only the following field must be completed:

Root Cause Tree (and if applicable Other – Causal Factor Description text field)
The Assigned To name or the Date Due field does not need to be completed.
The Root Cause Analysis must be left blank.
The codes and sub-categories have been concatenated in one field. Example: OP04 – Inadequate
Training. (See screen below).
The user will be able to select only the Code including the respective Sub-Category. Example:
“Preconditions for Unsafe Acts > CRM > CM01 – Lack of Assertiveness or Leadership”
Multiple Causal Codes can be selected by the user.
A Causal Factor Description field is also available for typing free text.
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See Section 5.1 for requirements applicable to the Root Cause.
See Section 6 for examples of suitable text for Root Cause.
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EDITING CORRECTIVE ACTION RECORDS (CAR)
4.4
Interim Action Tab
The interim corrective action tab is available in Q5AIMS but shall not be used for any ISAGO
audits.
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4.5
Final Action Tab
In the Final Action section the Auditee has to provide two important pieces of information:
1.
A description of the planned action to permanently correct the Finding or Observation
(corrective action plan).
2.
A description of the action which was taken to correct the Finding or Observation
(where applicable) (final corrective action).
The tab is divided into two sections to represent these two steps:
1.
The corrective action plan is completed in the Final Action Required field.
2.
The final corrective action is completed in the Final Action Taken field.
Note: It is important not to complete the Final Action Taken section, until the proposed action
contained in the Final Action Required has been accepted by the auditing entity. The Email CC
Address field is optional.
Note: If the non-conformity is an Observation and the Auditee chooses not to take
corrective action, the procedures in Section 4.5.3 of this manual must be followed.
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4.5.1
Part 1 - Final Action Required Section
The Final Action Required is used for recording the planned corrective action by the Auditee.
The following is to be completed:
-
Under Date Due, select the date by which the action is planned to be completed. This date
is for planning only.
-
Under Final Action Required, describe what action is planned to correct the nonconformity. This information should be completed as soon as possible after the audit, to
facilitate the submission to the auditing entity.
Note:
Both the Date Due and Final Action Required fields are mandatory and must be completed.
The description of the planned action must be written in the future tense.
See Section 5.2 for requirements applicable to Final Action Required.
See Section 6 for examples of suitable text for Final Action Required.
Do not proceed to Part 2 unless the auditing entity has accepted the Root
Cause and Final Action Required.
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4.5.2
Part 2 – Final Action Taken Section
The Final Action Taken must contain a detailed description of the corrective actions carried out
to permanently rectify the Finding or Observation. The following must be completed:
- Under Completed/Submitted by, select the Auditee Representative who has submitted
the evidence.
- Under Date Completed/Submitted, select the date on which all steps to correct the
Finding or Observation were completed.
- Under Final Action Taken, describe the actions which have been taken, including the
updating of manuals and documentation (revision and/or date). Local and regional
abbreviations and acronyms, while familiar to the Auditee, must be spelled out, to ensure
a clear understanding by reviewers of the report worldwide.
Note:
The Completed/Submitted by, Date Completed/Submitted, and Final Action Taken fields are
mandatory and must be completed.
Descriptions of the corrective action must be written in past tense and sentences similar to “see
document attached” must not be used as it adds no value to the corrective action. The final report
will not contain any kind of attachment and no attachments will be reviewed by any third party
reader. An accurate description of the corrective action must be used instead.
-
When the final action is complete, the
Completed/Submitted automatically gets selected.
checkbox
Change
Status
to
The system will automatically complete the details section with the name of the user who is
currently logged in, as well as the current date. The name and date can then be adjusted if
necessary. The date must correspond to the date on which the corrective action was
implemented.
Note:
Once the Change status to Completed/Submitted box is ticked, changes cannot be made
unless it is deselected and saved again.
See Section 5.3 for requirements applicable to Final Action Taken.
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EDITING CORRECTIVE ACTION RECORDS (CAR)
See Section 6 for examples of suitable text for Final Action Taken.
4.5.3
Observations Which Will Not be Actioned by the Auditee
For Observations, the Auditee has the option of taking no corrective action, or of beginning
corrective actions, but not completing them before the audit is closed. In either case, the following
applies.
Note: The Root Cause must always be completed, whether or not the observation is corrected by
the Auditee.
4.5.3.1
If no corrective action is taken at all, the following must still be completed:
- The Date Due field should be left blank, as there will be no corrective action.
- The phrase, “No corrective action” must be inserted into the Final Action
Required field.
- The phrase “No final corrective action.” must be inserted into the Final Action
Taken field.
- Click on Save. The Change Status to Completed/Submitted box is
automatically selected.
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4.5.3.2
If corrective action is initiated, but not completed before audit closure, then
complete the following:
- The Date Due field should be left blank, as the correction will not be completed
before audit closure.
- Complete the planned corrective action, to reflect what is planned in the Final
Action Required field.
- Insert the phrase, “No final corrective action” in the Final Action Taken field.
- Click on Save. The Change Status to Completed/Submitted box is
automatically selected.
Note: This situation would arise when an Auditee wanted a record of the corrective actions
taken, even though these corrective actions were not completed before audit closure.
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4.6
Review / Close Tabs
The Review and Close sections are completed by the auditing entity. These sections are used to
indicate what evidence has been reviewed in order to close the Finding or Observation.
If a CAR has been reviewed or closed, changes to the information inserted on the Final Action
section can no longer be made. If any update is required for a CAR that has been reviewed, the
auditing entity that closed the CAR must be contacted for authorization to make any amendments
to the CAR.
4.7
Docs Tab
The Docs tab can be used to attach documents related to each specific CAR. To attach a
document to a corrective action, the following must be completed:
-
Select Docs tab
-
Select Add Docs
-
Browse to locate the file
-
Save the document
Note: Even though documents can be attached to a specific CAR, statements such as “see
document attached” must not be used in the Final Action Taken Section, as the Final Audit
Report does not include any supporting documents.
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5
Requirements for Root Causes Corrective Actions
The closing of Findings and Observations after the audit will be quicker and easier if the
requirements below are followed. They will also facilitate the assessment and verification of
corrective actions by the auditing entity, as well as satisfying the requirements for
comprehensive, accurate and reliable audit report completion.
5.1
Root Cause
The following Root Cause Classification is available on the web and laptop application under
the CAR tab > Root Cause tab
ORGNAIZATIONAL INFLLUENCES
Area
Category
Resource
Management
Code
RM01
RM02
RM03
Organizational
Climate
Organizational
Processes
Inadequate
Supervision
Failed
Correct
Known
Problem
to
a
Supervisory
Violations
PREC UNSAFE
ONDITI
ONS
FOR
UNSAF
E
ACTS
SUPERVISON
Planned
Inappropriate
Activities
Physical
Environment
ISAGO Q5 Auditee Manual Ed 4
RM04
RM05
RM06
OC01
OC02
OC03
OC04
OP01
OP02
OP03
OP04
OP05
IS01
IS02
IS03
IS04
IS05
PA01
PA02
PA03
PA04
FP01
FP02
FP03
FP04
SV01
SV02
SV03
SV04
PN01
PN02
PN03
Sub-category
Insufficient human resources
Insufficient/ defective equipment/facilities available
Insufficient financial/budget resources, excessive cost
cutting
Insufficient selection process / qualification
Poor planning, prioritization
Other (description to be provided by Auditee)
Inadequate company culture
Inadequate HR policies
Inadequate organizational structure
Other (description to be provided by Auditee)
Inadequate oversight resources
Unclear/unavailable/inadequate
regulations,
standard
procedures
Inadequate operations
Inadequate training
Other (description to be provided by Auditee)
Failed to provide leadership and guidance
Failed to track performance
Failed to track qualification
Failed to provide/ensure adequate training
Other (description to be provided by Auditee)
Inappropriate employee scheduling / assigning/ manning
Inadequate Risk Assessment
Authorization to take unnecessary risks
Other (description to be provided by Auditee)
Supervisor failed to identify and correct inappropriate
behavior or unsafe tendencies
Supervisor
failed
to
correct
known
hazard/problem/error/inefficiency
Supervisor failed to report a hazard or unsafe tendencies
Other (description to be provided by Auditee)
Supervisor failed to enforce rules and regulations
Supervisor directed / authorized subordinates to violate
existing rules
Supervisor authorized unqualified person for work
Other (description to be provided by Auditee)
Restricted visibility, altitude, terrain, weather conditions
Inadequate lighting, noise, vibration
Inadequate cleanliness, surface conditions
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Area
Category
Technological
Environment
Psychological
and Physical
Conditions
Code
PN04
PN05
TN01
TN02
TN03
TN04
TN05
PC01
PC02
PC03
PC04
PC05
PC06
PC07
Personal
Readiness
CRM
PC08
PR01
PR02
PR03
PR04
PR05
CM01
CM02
CM03
CM04
CM05
CM05
Decision
Errors
Skill
Errors
Based
CM06
DE01
DE02
DE03
DE04
SE01
UNSAFE ACTS
SE02
SE03
Perception
Errors
Exceptional
violations
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SE04
SE05
PE01
PE02
PE03
EV01
EV02
EV03
Sub-category
Inadequate facilities/walk/road layout, signing, marking
Other (description to be provided by Auditee)
Inappropriate/poor design of equipment, tool, parts,
material
Inappropriate automation, function, reliability
Inappropriate interface design
Inappropriate communications system
Other (description to be provided by Auditee)
Inattention, apathy, complacency, boredom, distraction,
stress, exhaustion (Burnout)
Channelized
attention
and
actions,
confusion,
disorientation
Personality style
Illness, sickness
Effects of alcohol, drugs (before or while on duty)
Inadequate experience for situation, insufficient reaction
time
Misperception of operational conditions , incorrect
interpretation and understanding
Other (description to be provided by Auditee)
Inadequate Rest
Inadequate physical fitness, Insufficient diet, nutrition
Self-medication and , unreported medical conditions
Inadequate personal preparation
Other (description to be provided by Auditee)
Lack of assertiveness or leadership
Lack of planning or preparation, inadequate briefing,
insufficient re-planning
Poor workload management or task delegation
Authority gradient, poor teamwork
Lack of cross-monitoring performance, supportive feedback
or acknowledgement
Poor communication of critical information and poor
decision making
Other (description to be provided by Auditee)
Inadequate risk evaluation during operation, misjudging
Ignored caution, warning
Task mis-prioritization
Other (description to be provided by Auditee)
Incorrect operation/handling of equipment / inappropriate
use of automation
Incorrect operations / handling equipment
Inadvertently activating or deactivating equipment, controls
or switches
Failure to see and react / fail
Other (description to be provided by Auditee)
Error due to misperception, illusion, disorientation,
misjudgment
Spatial disorientation, vertigo, visual illusion
Other (description to be provided by Auditee)
Lack of discipline
Rules, regulations, procedures not followed
Intentional bending the rules, procedures, policies by
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REQUIREMENTS FOR CORRECTIVE ACTIONS
Area
Category
Code
EV04
RV01
Routine
violations
RV02
RV03
Sub-category
individual or team without cause or need
Others (description to be provided by Auditee)
Widespread, routine, systemic , habitual violation by
individual or team
Violation based on Risk Assessment
Other (description to be provided by Auditee)
Particular (industry known) examples are provided below for some of the Sub-categories.
Code
RM01
RM02
RM04
RM05
OC01
OC02
OC03
OP01
OP02
Example
 staffing, manning for task

improper infrastructure (equipment , facilities, material, technology support,
intelligence)

inadequate procurement & acquisition process

inadequate attrition or disposal policies

long selection process

people with improper qualification selected

unavailable training

conflicting or inadequate prioritization

conflicting goals

inadequate policies impacting planning or availability of resources

inadequate norms, values, beliefs, policies

tolerance to drugs and alcohol

tolerance to abundance or deviation from the rules

inadequate incentive system affecting motivation

unstable workforce (hiring, retention)

pressure on employees (evaluations, promotions), industrial, union , commercial,
peer pressure

unclear lines of reporting

inadequate delegation of authority

lack of formal accountabilities for actions

inadequate accessibility or visibility of supervisor

inappropriate organizational changes (personnel/aircraft/equipment) impacting
the carrying out of duties

management without sufficient support, planning or oversight

inadequate risk management, risk assessment

insufficient safety programs

operations, philosophy is flawed or accepts unnecessary risk

insufficient company or contracted training programs

standards, objectives, procedure, instruction, guidance, information
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Code
Example
 revision process

documentation

communication of changes

high operational tempo, quotas and time pressure

workload (additional duties and off-duty activities)

KPRs and measurement system

schedules, deficient planning

provided training was not sufficient

training was not focus on job duties

training is not standardized

there is only OJT provided

not providing policy, instruction, information

inadequate task delegation/prioritization

personality conflict with team member

lack of feedback

task allocation

task achievements

adequate rest period

no tracking system in place

records availability and control

no training program established

no training scheduled

no tracking system in place

training not scheduled on time

records availability

excessive workload over-tasking

inadequate personnel

resources with Limited Recent Experience (not authorized to perform particular
task)

resources with Limited Total Experience (insufficient experience to perform the
task)

resources not proficient to perform task
PA02

Lack of evaluation of the risks associated with a task
SV01

supervisor tolerated
individuals
SV02

provided inadequate documents

falsified documents / records
OP03
OP04
IS01
IS02
IS03
IS04
PA01
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unwritten or unofficial (“ De facto”) policy followed by
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REQUIREMENTS FOR CORRECTIVE ACTIONS
The Auditee will carry out the Root Cause Analysis according to the Auditee’s internal
process.
 The codes and sub-categories have been concatenated in one field. Example: OP04 –
Inadequate Training (See screen below).
 The Auditee must only select the Code including the respective Sub-Category.
Example: “Preconditions for Unsafe Acts>CRM>CM01 – Lack of Assertiveness or
leadership.
 The Auditee can select multiple causal codes
 The Other – Causal Factor Description field is also available for typing free text, in
case additional information need to be entered to support the chosen RC from the tree
or to add RC in case Auditee identified different RC than the RC tree options.
When completing the Root Cause Tree or, if applicable, in the ‘Other – Causal Factor
Description’ field, the following rules shall be followed
Root Cause :
5.2
1
The Root Cause Tree must be check marked for all CARs, even if no corrective action is
taken.
2
Standard, generalized phrases or brief statements such as “GOSARP not considered”
do not provide an appropriate Other – Causal Factor Description
3
The ‘Other – Causal Factor Description’ must not be a copy paste or an extract of the
Finding and/or Observation wording.
4
The RC must not contradict the reasoning and evidence recorded in the non-conformity,
or any other assessment information in the CAR.
Final Action Required
When completing the Final Action Required (FAR) section, the following rules shall be
followed
The FAR must contain:
1
A brief description of the changes planned to correct the Finding or Observation. It must
be written in the future tense.
2
Changes planned for documentary structures/manuals and if available, references for
the planned revisions and/or amendments.
3
For assessments of “not implemented”, a description of how the changes will be
implemented is required.
4
Estimated Date(s) of when the corrective action(s) is expected to be implemented.
Note: The Estimated Date is “Date Due” in the Final Action tab. This date should be completed
when a corrective action is to be taken, otherwise, it remains blank.
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5.3
Final Action Taken
When completing the Final Action Taken (FAT) section, the following rules shall be followed,
FAT must contain:
1
A description of the corrective action taken to close the Finding or Observation.
The FAT must address:
a. the elements of GOSARP which resulted in the nonconformity;
b. the original non-conformity, as recorded in by the Auditor;
c. the Root Cause.
The corrective action must describe how the documentation and implementation deficiencies (changes
to documentation, operational structures, programs, processes, procedures, etc., including action taken
to address the gap in the implementation) were addressed, to close the Finding or Observation
permanently.
2
As completed actions, they must be written in the past tense.
3
Documentation deficiencies:
a. Changes made to controlled documentation must include manual names or acronyms
revision/amendment references and/or dates, as available.
b. Dates of documentation cannot be after the “Date Implemented” or after the CAR audit closure date.
c.
Brief descriptions of the kind of changes made to documentation. Copy pasting of individual
processes, procedures etc. from the Provider documentation must not be included.
d. Distribution and receipt of documentation to all affected parties must be provided.
4
Implementation deficiencies: details of how deficiencies were corrected and implemented, shall include:
a. Traceable evidence of implementation, e.g. records, reports, audit, training dates, schedules, rosters,
meeting minutes, management reviews, analysis, etc., including applicable dates, revisions,
locations, names and any other associated information.
b. Detailed descriptions of how applicable corrective actions were implemented.
c.
Distribution of revisions to documentation is seldom sufficient to confirm implementation. If the
deficiency concerned staff or crew training, details must be provided on how and when training had
begun for the staff or crew.
d. There are situations when corrective actions cannot commence or be completed before audit closure
deadlines, for example, implementing initial training when there is no new staff to train, or when there
is insufficient data available to implement review or analysis programs.
e. In such cases, the Auditee must provide the reasons why actual implementation could not be
confirmed, as well as all actions taken to ensure implementation when possible.
5
The corrective action cannot contradict the reasoning provided for the RC analysis.
6
The “Completed/Submitted By” field must contain the Auditee Representative name and the “Date
Implemented” must contain the appropriate date.
The Date Implemented cannot be after the Review Date, or after the CAR or audit closure date(s).
Since the auditing entity are no longer required to provide a description of all evidence of documentation
and implementation accepted within the Review field, the requirement that the FAT clearly describes all
traceable details is further enhanced.
To reinforce the importance of FAT it’s essential that FAT includes:
1. Items to be recorded to address documentation deficiencies:
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REQUIREMENTS FOR CORRECTIVE ACTIONS
i) Document name (title) and abbreviation / acronym (abbreviation / acronym optional)
(ii) Version (edition/revision, issue/revision)
(iii) Effective or Publication date
(iv) Distribution date
(v) Affected section(s) of document
(vi) Brief description of changes made to documentation
2. Items to be recorded to address implementation deficiencies:
(i) Traceable evidence of implementation
(ii) Detailed descriptions of how applicable corrective actions were implemented
Examples of acceptable FATs:
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6
Examples of Root Causes and Corrective Actions
The examples below contain:





Typical Root Cause ;
The type of descriptions that are needed for evidence of corrective actions;
Descriptions and references of the amendments/revisions to manuals and documentation;
Descriptions of how corrective actions were implemented;
Unsuitable Root Cause Analyses and corrective actions.
Correct Example 1:
Finding:
The Provider does not have procedures to ensure, when an aircraft is parked unattended or
with no one on board, doors are closed, locked and sealed, and any steps are removed.
Assessment:
Not Documented, Implemented
Root Cause:
OP02 – Unclear / unavailable / inadequate regulations, standard procedures
Final Action Required:
The Ramp Operational Safety Procedures (ROSP) will be revised assigning responsibility to
the ramp agent. The target completion date will be in Oct 2014 and the relevant staff will be
briefed. The Ramp Operational Safety Familiarization (ROSF) will be updated.
Final Action Taken:
The Ramp Operational Safety Procedures (ROSP, Revision 1, dated 15 Sep 2014) was
revised to include the procedures to ensure, when an aircraft is parked unattended or with no
one on board, doors are closed, locked and sealed, and any steps are removed. This was
documented in Chapter 7.3 Unattended Aircraft Parking, on page 88.
Implementation was achieved by: the Document Change Notification (DCN 777-11, 15 Sep
2014) of the ROSP, which was published and disseminated via intranet mail on 02 Oct 2014
and acknowledged by management recipients.
In addition, briefings were conducted to all the Ground Handling personnel on 03, 10 and 21
Oct 2014 with signed confirmation of attendance forms.
Furthermore the Ramp Operational Safety Familiarization (ROSF) training material content
was updated as per ROSF Revision 3, 20 Sep 2014 to ensure new ramp employees will be
trained in this procedure.
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INCORRECT Example 2:
Finding:
The Provider does not have procedures to ensure, when an aircraft is parked unattended or
with no one on board, doors are closed, locked and sealed, and any steps are removed.
Assessment:
Not Documented, Implemented
(INCORRECT) Root Cause:
OC03 – Lack of formal accountabilities for actions.
Note: The RC does not address the lack of procedures
(INCORRECT) Final Action Required:
The procedures will be revised assigning responsibility to the ramp agent.
Note: FAR does not include action planned to take to address the gap in the implementation.
(INCORRECT) Final Action Taken:
The procedures were revised to include the procedures to ensure, when an aircraft is parked
unattended or with no one on board, doors are closed, locked and sealed, and any steps are
removed. These procedures have been already published.
Note: The Final Action Taken does not address the RC and does not contain traceable
evidences of implementation. The FAT does not contain the name of the procedure that was
revised/developed, issue/effective date is missing, as well revision number and sub-reference.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
Correct Example 4:
Finding:
The Provider does not utilize auditing as a method for the monitoring of external service
providers as specified in ORM-S 3.6.2.
Assessment:
Not Documented, Not Implemented (Observation)
Root Cause:
RM05: Inadequate policies impacting planning or availability of resources
Final Action Required:
ABC Ground Services will include the monitoring of external service providers in the Quality
Department audit plan, which will be documented in the Quality Manual. The target completion
date will be in Sep 2014. Implementation will be demonstrated by way of the document
change request form, publication and distribution of the revised Quality Manual, audit plan and
audit records of external service providers.
Final Action Taken:
Implementation was demonstrated by: the Bulletin of Changes (BCH 03/2014, 01 Oct 2014) of
the QM, which was published and disseminated via intranet mail on 12 Oct 2014 and
acknowledged by management recipients.
The Internal Audit Plan was revised to include the external service providers, XYZ Services
and HJK Baggage Handling Co, which were audited on 18 and 25 Oct 2014 respectively
based on above mentioned procedures. Two audits have been performed as per the revised
audit plan with one audit cancelled due to a political strike.
The Audit reports ABC-XYZ-audit report 06/12 and ABC-HJK-audit report 07/12 were
completed and closed on 02 Nov 2014 and 05 Nov 2014, respectively.
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INCORRECT Example 5:
Finding:
The Provider does not utilize auditing as a method for the monitoring of external service
providers as specified in ORM-S 3.6.2.
Assessment:
Not Implemented (Observation)
(INCORRECT) Root Cause:
IS01 – Failed to provide leadership and guidance
Note: The RC does not address the finding. While leadership and guidance may be a very
generalized root cause, it does not address why the auditing was not utilized in the company.
(INCORRECT) Final Action Required:
We will evaluate the Finding with the Headquarters.
Note: The Final Action Required provides no information on what will be the course of actions
that the GSP will put in place.
(INCORRECT) Final Action Taken:
The Internal Audit Plan was revised to include the external service providers. These were
audited in 2014. The Audit reports are available and issued by the Lead Auditor.
Note: The Final Action Taken provides no traceable details, e.g. date when audit plan was
issued, name of the audits completed, audit reports date.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
Correct Example 6:
Finding:
The Provider did not have a company standard to periodically review and update the training
program to meet company requirements and those of relevant authorities and customer
airlines.
Assessment:
Not Documented, Not Implemented.
Root Cause A:
OP02 Inadequate standard procedures
Final Action Required:
The requirement to periodically review and update the corporate training program will be
included in a controlled document and evidence of the required review of the training program
will be provided.
Final Action Taken:
th
A revision to the Training Program (ABC/QP-PX-01-2014 was issued (Revision 03 dated 26
February 2014). Section 5.3.5 now includes the requirement to periodically review and update
all company training programs. The requirement details responsibility for the review and
update, process flow chart, methodology and periodicity.
th
An internal memo (2014/97 dated 28 February 2014) was issued by the Training department
requiring persons in charge of individual training syllabi to periodically review and updates
training material, and it has been placed on the company intranet.
Samples of the already updated training materials: Ramp Security course (RAMPSEC-1
22MAR12), Ramp Safety Awareness course (RAMSAF-1 23MAR12) and Baggage Carts
Handling (BAGCAR-1 25MAR12) were provided as proof of implementation.
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INCORRECT Example 7:
Finding:
The Provider did not have a company standard to periodically review and update the training
program to meet company requirements and those of relevant authorities and customer
airlines
Assessment:
Not Documented, Not Implemented.
(INCORRECT) Root Cause:
OP02 – Procedimiento de entrenamiento no esta controlado
Note: The Root Cause is not written in English.
Final Action Required:
The requirement to periodically review and update the corporate training program will be
included in a controlled document and evidence of the required review of the training program
will be provided.
Note: OK
(INCORRECT) Final Action Taken:
The Training Program (ABC/QP-PX-01-2014) is going to be issued soon. Section 5.3.5 will
include the requirement to periodically review and update all company training programs. The
requirement details responsibility for the review and update, process flow chart, methodology
and periodicity.
An internal memo will be issued by the Training department requiring persons in charge of
individual training syllabi to periodically review and update training material, and will be placed
on the company intranet.
Samples of the updated training materials will be available: Ramp Security, Ramp Safety
Awareness and Baggage Carts Handling were provided as proof of implementation.
Note: The Final Action Taken is written in future tense which means that the corrective actions
were not completed yet. Additionally some traceable details are missing, e.g. date of the
internal memo, date of the training material that was already revised / reviewed.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
Correct Example 8:
Finding:
The Provider has a training and qualification program for personnel who operate aircraft
access doors but the training syllabus was not documented. Training records for 2 personnel
who provide the aircraft access door operation were missing.
Assessment:
Not Documented, Not Implemented.
Root Cause:
OP04 – Inadequate training.
Final Action Required:
The training, evaluation and qualification program for personnel who operate aircraft access
doors will be included in a controlled document. The follow up and tracking process to ensure
training records accessibility and accuracy will be reinforced.
Final Action Taken:
The Training program for Operation Control Center (PPR/SY-ZK-15-2014) was issued
th
(Revision 01 dated 26 May 2014) and distributed. Section 3 of the document deals with the
requirements for initial and recurrent training of personnel who operate aircraft access doors.
A special Internal Audit SP/PR/2014 was conducted on internal records of Ground Operations’
staff, with 100% sampling to check the records. Corrective action on some non-conformities
were taken and the audit was closed,
The Audit Plan process has been amended to include an audit on the training syllabi and
training records of Operational Control personnel, on an annual basis. This process is
QC/PLAN/115 and is in Chapter 6 of the Quality Manual, Rev 6 dated 03 May 2014.
Internal bulleting GRN OPS 12/2014 addressing the above requirements has been sent to all
involved personnel with acknowledge receipt form signed to proof that it has been sighted.
Additionally also uploaded in the intranet system.
Evidence has been provided of the training records for personnel who completed the Airbus
th
A330 and Boeing B747-400 door operating course held on 13 June 2014.
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INCORRECT Example 9:
Finding:
The Provider has a training and qualification program for personnel who operate aircraft
access doors but the training syllabus was not documented. Training records for 2 personnel
who provide the aircraft access door operation were missing.
Assessment:
Not Documented, Not Implemented.
(INCORRECT) Root Cause:
OP02 Inadequate standard procedure
Note: The Root Cause only addresses the lack of documentation. It does not address why
training records of two personnel were missing.
(INCORRECT) Final Action Required:
The training, evaluation and qualification program for personnel who operate aircraft access
doors will be included in a controlled document.
Note: The Final Action Required only addresses the lack of documentation, it does not specify
what the provider will implement in order to ensure personnel are training and training records
are available.
(INCORRECT) Final Action Taken:
The Training program for Operation Control Center was issued and distributed.
Note: The Final Action Taken only addresses the lack of documentation and there is no
traceability for the evidences provided, e.g. date of the training program. There is no
information if the corrective action was implemented and how.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
Correct Example 10:
Finding:
The Provider did not have any procedure or instructions for security control for vehicles that
enter into security restricted areas in or around cargo terminals
Assessment:
Not Documented, Not Implemented
Root Cause:
PN05 – Lack of security controls.
Final Action Required:
The process for the implementation of access control for vehicles entering into security
restricted areas will be added to the aviation security program chapter 4. The vehicle checks
will be performed and recorded by the security personnel. Staff will be trained for new
procedures. The estimated date of implementation is June 2014.
.
Final Action Taken:
The process for the implementation of access control for vehicles before entering into security
restricted areas has been added to the aviation security program C-CCS-HB-031 version 1.1 /
30.06.2014, chapter 4.1.2 page 5 – 6 and distributed to all applicable personnel.
The Work Order A-CCS-9 with a detailed description "how to perform vehicle checks" was
th
distributed to security staff on 12 July 2014.
th
A familiarization session for all security involved personnel was held on 15 July 2014.
Satisfactory performance of vehicle security checks was confirmed by the station manager
during two random station inspections completed on 12 August 2014 and on 01 Sep 2014.
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Correct Example 11:
Finding:
It was observed that aircraft chocks used in operations were not wide enough for the aircraft
wheels, as documented in Standard Operating Procedure AP P EST05 Chocking and the
Working Instructions AP WI EST05 Chocking 3.1.
Assessment:
Documented, Not Implemented
Root Cause:
OP03 Inadequate Operations
Final Action Required:
Standard Operating Procedures and Instructions for Chocking (reference EST05) will be
revised. An instruction for the ramp staff will be produced to ensure correct implementation.
The clarity related to different responsibilities will be addressed in the revised document.
Final Action Taken:
Standard Operating Procedures and Instructions for Chocking have been revised (references
AP/P/EST05 Rev 15 and AP/W/EST05 Rev. 19, both dated 03 Jan 2014) and distributed to all
applicable personnel.
It has been also agreed and documented that the each instruction or procedure will be sent for
approval to a Head of Ramp operation to ensure consistency.
th
An instruction for the ramp staff was displayed in the staff canteen on 10 January, 2014.
Refresher training sessions were conducted on 12, 15, 18 and 25 January 2014.
Random inspections by the Quality Manager on 05 Feb, 02 Mar and 28 Mar 2014 have
indicated that the staff is now following the revised procedure.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
Correct Example 12:
Finding:
ULD storage procedures are documented in the Cargo international Transportation Manual
(CITM), Ch. 11, 11.7.4.1 and UGOM, Ch. 5, 5.1.2 (6), but the procedures are not
implemented, as damaged ULDs are stored together with airworthy ULDs.
Assessment:
Documented, Not Implemented
Root Cause:
FP04 – Supervisor failed to segregate defective equipment
Final Action Required:
The ULD control department will ensure that all staffs are instructed to follow published
procedures for storing un-airworthy ULDs separately. The damaged and un-airworthy ULDs
will be sorted and then placed in an isolated location. Customer airlines will be notified of the
procedural requirement for separate storage of un-airworthy ULDs.
Final Action Taken:
nd
All respective personnel were instructed via internal order no 15, dated 22 March 2014, to
follow the existing procedure documented in the Cargo international Transportation Manual
Chapter 11.
Un-airworthy ULDs were being stored separately, verified by a quality inspection performed by
th
Quality Assurance department on 13 April 2014.
Customer airlines were notified during the AOC meeting that was held on 01-May-2014 and it
was recorded in the meeting minutes that customer airline will respect new procedure as
implemented by the provider.
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INCORRECT Example 13:
Finding:
ULD storage procedures are documented in the Cargo international Transportation Manual
(CITM), Ch. 11, 11.7.4.1 and UGOM, Ch. 5, 5.1.2 (6), but the procedures are not
implemented, as damaged ULDs are stored together with airworthy ULDs.
Assessment:
Documented, Not Implemented
Root Cause:
FP04 – Supervisor failed to segregate defective equipment.
Note: OK
(INCORRECT) Final Action Required:
The Ground Procedures Manual (GOPM) will be updated ensuring the ULD damage control
performs regular checks in the ULD storage area.
Note: The Final Action Required addresses Documentation instead of Implementation.
(INCORRECT) Final Action Taken:
The Ground Procedures Manual (GOPM) has been updated and distributed and in chapter 236-1 describes the process to ensure the ULD damage control regular checks in the ULD
storage area are performed.
Note: The Final Action Taken addresses Documentation instead of Implementation. The
Finding assessment was “Documented, Not Implemented”, so primarily, the implementation
needed to be addressed. FAT is inconsistent to the nature of the finding.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
Correct Example 14:
Observation:
The Provider did not have a process to ensure that operational personnel are physically and
mentally fit for duty.
Assessment:
Not Documented, Not Implemented (Observation)
Root Cause:
PR04 – Inadequate personal preparation
Final Action Required:
The process will be documented in the Corporate Quality manual, revision 5, dated July 2014.
Implementation will be ensured by issuing an Employee brochure by the end of July and staff
will be made aware of this new process during regular staff meetings.
Final Action Taken:
No final corrective action
Note: This example is only applicable to an Observation. GSP originally planned to address
this observation but later on decided not to take any action.
Correct Example 15:
Observation:
The Provider did not have a risk management process that is applicable to station operations
Assessment:
Not Documented, Not Implemented (Observation)
Root Cause:
PA02 – Inadequate Risk Assessment
Final Action Required:
No corrective action
Final Action Taken:
No final corrective action
Note: This example is only applicable to an Observation and when the GSP does not plan, nor
has the intention of implementing any corrective action.
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INCORRECT Example 16:
Observation:
The Provider did not have a risk management process that is applicable to station operations
Assessment:
Not Documented, Not Implemented
(INCORRECT) Root Cause Analysis:
DE01 – Inadequate risk evaluation during operation, misjudging.
Note: This is not a proper root cause, does not specify why there is no risk management
process.
(INCORRECT) Final Action Required:
No
Note: This example is only applicable to an Observation and when the GSP does not plan, nor
has the intention of implementing any corrective action. FAR must include sentence “No
Corrective Action”.
(INCORRECT) Final Action Taken:
No
Note: This example is only applicable to an Observation and when the GSP does not plan, nor
has the intention of implementing any corrective action. FAT must include sentence “No Final
Corrective Action”.
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EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS
6.1
Unsuitable Examples of Corrective Actions
Final Action Required
Example 1:
The requirement will be documented and implemented.
Example 2:
A procedure will be developed and will be submitted along with Final
Action Taken.
Example 3:
The Procedure will be updated.
Statements like in the examples can not be accepted as essential details are not
provided to ensure the finding / observation will be correctly addressed by the GSP.
Final Action Taken
Example 1:
Please see attached Ground Operational manual, chapter 5 where the
standard is documented.
Example 2:
This process is now documented.
Example 3:
CPM Chapter 6 was issued to address the policy of the GOSARP.
Statements like in the examples can not be accepted as no corrective action description
is provided to ensure the finding / observation was permanently addressed.
Statements such as “see document attached” must not be applied in the Final Action
Taken as supporting documents, used during the verification process, are not part of
the final audit report. The verification is done by the Auditor and not by IATA or the
reader of the report.
Traceable evidence shall be always recorded as name of the document revised,
revision number, date of issue, distribution, sub-reference and proof of implementation
as training records, meeting minutes, audit report completed etc.
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www.iata.org
ISBN 978-92-9252-475-3