Isago q5 Auditee Manual Ed4 Jan2015

51
ISAGO Q5 AIMS Effective January 2015 Edition 4th Auditee Manual

description

N/A

Transcript of Isago q5 Auditee Manual Ed4 Jan2015

Page 1: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 AIMS Effective January 2015

Edition4th

Auditee Manual

Page 2: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 AIMS Auditee ManualISBN No: 978-92-9252-475-3© 2015 International Air Transport Association. All rights reserved.Montreal—Geneva

NOTICEDISCLAIMER. The information contained in this publication is subject to constant review in the light of changing government requirements and regula-tions. 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 ev-ery 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 Interna-tional 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 en-tity 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 trans-mitted in any form by any means, electronic or mechanical, including photocopying, record-ing or any information storage and retrieval sys-tem, without the prior written permission from:

Senior Vice PresidentSafety, Operations & Infrastructure

International Air Transport Association800 Place Victoria

P.O. Box 113Montreal, Quebec

CANADA H4Z 1M1

Page 3: Isago q5 Auditee Manual Ed4 Jan2015

TABLE OF CONTENTS

ISAGO Q5 Auditee Manual Ed 4 Page 1 January 2015

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

Page 4: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 2 January 2015

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

Page 5: Isago q5 Auditee Manual Ed4 Jan2015

INTRODUCTION

ISAGO Q5 Auditee Manual Ed 4 3 January 2015

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.

Page 6: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 4 January 2015

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:

Page 7: Isago q5 Auditee Manual Ed4 Jan2015

INTRODUCTION

ISAGO Q5 Auditee Manual Ed 4 5 January 2015

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.

Page 8: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 6 January 2015

INTENTIONALLY LEFT BLANK

Page 9: Isago q5 Auditee Manual Ed4 Jan2015

ACCESSING THE SYSTEM

ISAGO Q5 Auditee Manual Ed 4 7 January 2015

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 (Internet Explorer, Firefox, Google Chrome

1…).

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.

1Google Chrome is not recommended to use due to some compatibility issues.

Page 10: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 8 January 2015

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:

Page 11: Isago q5 Auditee Manual Ed4 Jan2015

ACCESSING CORRECTIVE ACTIONS RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 9 January 2015

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.

Page 12: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 10 January 2015

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:

Page 13: Isago q5 Auditee Manual Ed4 Jan2015

ACCESSING CORRECTIVE ACTION RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 11 January 2015

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.

Page 14: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 12 January 2015

Intentionally Left Blank

Page 15: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 13 January 2015

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.

Page 16: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 14 January 2015

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.

Page 17: Isago q5 Auditee Manual Ed4 Jan2015

EDITING CORRECTIVE ACTION RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 15 January 2015

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.

Page 18: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 16 January 2015

See Section 5.1 for requirements applicable to the Root Cause.

See Section 6 for examples of suitable text for Root Cause.

Page 19: Isago q5 Auditee Manual Ed4 Jan2015

EDITING CORRECTIVE ACTION RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 17 January 2015

4.4 Interim Action Tab

The interim corrective action tab is available in Q5AIMS but shall not be used for any ISAGO audits.

Page 20: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 18 January 2015

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.

Page 21: Isago q5 Auditee Manual Ed4 Jan2015

EDITING CORRECTIVE ACTION RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 19 January 2015

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 non-conformity. 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.

Page 22: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 20 January 2015

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 checkbox Change Status to Completed/Submitted automatically gets selected.

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.

Page 23: Isago q5 Auditee Manual Ed4 Jan2015

EDITING CORRECTIVE ACTION RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 21 January 2015

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.

Page 24: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 22 January 2015

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.

Page 25: Isago q5 Auditee Manual Ed4 Jan2015

EDITING CORRECTIVE ACTION RECORDS (CAR)

ISAGO Q5 Auditee Manual Ed 4 23 January 2015

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.

Page 26: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 24 January 2015

INTENTIONALLY LEFT BLANK

Page 27: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 25 January 2015

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

Area Category Code Sub-category

OR

GN

AIZ

AT

ION

AL I

NF

LL

UE

NC

ES

Resource Management

RM01 Insufficient human resources

RM02 Insufficient/ defective equipment/facilities available

RM03 Insufficient financial/budget resources, excessive cost cutting

RM04 Insufficient selection process / qualification

RM05 Poor planning, prioritization

RM06 Other (description to be provided by Auditee)

Organizational Climate

OC01 Inadequate company culture

OC02 Inadequate HR policies

OC03 Inadequate organizational structure

OC04 Other (description to be provided by Auditee)

Organizational Processes

OP01 Inadequate oversight resources

OP02 Unclear/unavailable/inadequate regulations, standard procedures

OP03 Inadequate operations

OP04 Inadequate training

OP05 Other (description to be provided by Auditee)

UN

SA

FE

S

UP

ER

VIS

ON

Inadequate Supervision

IS01 Failed to provide leadership and guidance

IS02 Failed to track performance

IS03 Failed to track qualification

IS04 Failed to provide/ensure adequate training

IS05 Other (description to be provided by Auditee)

Planned Inappropriate Activities

PA01 Inappropriate employee scheduling / assigning/ manning

PA02 Inadequate Risk Assessment

PA03 Authorization to take unnecessary risks

PA04 Other (description to be provided by Auditee)

Failed to Correct a Known Problem

FP01 Supervisor failed to identify and correct inappropriate behavior or unsafe tendencies

FP02 Supervisor failed to correct known hazard/problem/error/inefficiency

FP03 Supervisor failed to report a hazard or unsafe tendencies

FP04 Other (description to be provided by Auditee)

Supervisory Violations

SV01 Supervisor failed to enforce rules and regulations

SV02 Supervisor directed / authorized subordinates to violate existing rules

SV03 Supervisor authorized unqualified person for work

SV04 Other (description to be provided by Auditee)

PR

EC

ON

DIT

I

ON

S

FO

R

UN

SA

F

E

AC

TS

Physical Environment

PN01 Restricted visibility, altitude, terrain, weather conditions

PN02 Inadequate lighting, noise, vibration

PN03 Inadequate cleanliness, surface conditions

Page 28: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 26 January 2015

Area Category Code Sub-category

PN04 Inadequate facilities/walk/road layout, signing, marking

PN05 Other (description to be provided by Auditee)

Technological Environment

TN01 Inappropriate/poor design of equipment, tool, parts, material

TN02 Inappropriate automation, function, reliability

TN03 Inappropriate interface design

TN04 Inappropriate communications system

TN05 Other (description to be provided by Auditee)

Psychological and Physical Conditions

PC01 Inattention, apathy, complacency, boredom, distraction, stress, exhaustion (Burnout)

PC02 Channelized attention and actions, confusion, disorientation

PC03 Personality style

PC04 Illness, sickness

PC05 Effects of alcohol, drugs (before or while on duty)

PC06 Inadequate experience for situation, insufficient reaction time

PC07 Misperception of operational conditions , incorrect interpretation and understanding

PC08 Other (description to be provided by Auditee)

Personal Readiness

PR01 Inadequate Rest

PR02 Inadequate physical fitness, Insufficient diet, nutrition

PR03 Self-medication and , unreported medical conditions

PR04 Inadequate personal preparation

PR05 Other (description to be provided by Auditee)

CRM CM01 Lack of assertiveness or leadership

CM02 Lack of planning or preparation, inadequate briefing, insufficient re-planning

CM03 Poor workload management or task delegation

CM04 Authority gradient, poor teamwork

CM05 Lack of cross-monitoring performance, supportive feedback or acknowledgement

CM05 Poor communication of critical information and poor decision making

CM06 Other (description to be provided by Auditee)

UN

SA

FE

AC

TS

Decision Errors

DE01 Inadequate risk evaluation during operation, misjudging

DE02 Ignored caution, warning

DE03 Task mis-prioritization

DE04 Other (description to be provided by Auditee)

Skill Based Errors

SE01 Incorrect operation/handling of equipment / inappropriate use of automation

SE02 Incorrect operations / handling equipment

SE03 Inadvertently activating or deactivating equipment, controls or switches

SE04 Failure to see and react / fail

SE05 Other (description to be provided by Auditee)

Perception Errors

PE01 Error due to misperception, illusion, disorientation, misjudgment

PE02 Spatial disorientation, vertigo, visual illusion

PE03 Other (description to be provided by Auditee)

Exceptional violations

EV01 Lack of discipline

EV02 Rules, regulations, procedures not followed

EV03 Intentional bending the rules, procedures, policies by

Page 29: Isago q5 Auditee Manual Ed4 Jan2015

REQUIREMENTS FOR CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 27 January 2015

Area Category Code Sub-category

individual or team without cause or need

EV04 Others (description to be provided by Auditee)

Routine violations

RV01 Widespread, routine, systemic , habitual violation by individual or team

RV02 Violation based on Risk Assessment

RV03 Other (description to be provided by Auditee)

Particular (industry known) examples are provided below for some of the Sub-categories.

Code Example

RM01 staffing, manning for task

RM02 improper infrastructure (equipment , facilities, material, technology support,

intelligence)

inadequate procurement & acquisition process

inadequate attrition or disposal policies

RM04 long selection process

people with improper qualification selected

unavailable training

RM05 conflicting or inadequate prioritization

conflicting goals

inadequate policies impacting planning or availability of resources

OC01 inadequate norms, values, beliefs, policies

tolerance to drugs and alcohol

tolerance to abundance or deviation from the rules

OC02 inadequate incentive system affecting motivation

unstable workforce (hiring, retention)

pressure on employees (evaluations, promotions), industrial, union , commercial,

peer pressure

OC03 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

OP01 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

OP02 standards, objectives, procedure, instruction, guidance, information

Page 30: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 28 January 2015

Code Example

revision process

documentation

communication of changes

OP03 high operational tempo, quotas and time pressure

workload (additional duties and off-duty activities)

KPRs and measurement system

schedules, deficient planning

OP04 provided training was not sufficient

training was not focus on job duties

training is not standardized

there is only OJT provided

IS01 not providing policy, instruction, information

inadequate task delegation/prioritization

personality conflict with team member

lack of feedback

IS02 task allocation

task achievements

adequate rest period

IS03 no tracking system in place

records availability and control

IS04 no training program established

no training scheduled

no tracking system in place

training not scheduled on time

records availability

PA01 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 unwritten or unofficial (“ De facto”) policy followed by

individuals

SV02 provided inadequate documents

falsified documents / records

Page 31: Isago q5 Auditee Manual Ed4 Jan2015

REQUIREMENTS FOR CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 29 January 2015

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 :

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.

5.2 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.

Page 32: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 30 January 2015

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:

Page 33: Isago q5 Auditee Manual Ed4 Jan2015

REQUIREMENTS FOR CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 31 January 2015

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:

Page 34: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 32 January 2015

Intentionally Left Blank

Page 35: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 33 January 2015

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.

Page 36: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 34 January 2015

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.

Page 37: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 35 January 2015

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.

Page 38: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 36 January 2015

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.

Page 39: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 37 January 2015

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: A revision to the Training Program (ABC/QP-PX-01-2014 was issued (Revision 03 dated 26

th

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. An internal memo (2014/97 dated 28

th 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.

Page 40: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 38 January 2015

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.

Page 41: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 39 January 2015

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 (Revision 01 dated 26

th 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 A330 and Boeing B747-400 door operating course held on 13

th June 2014.

Page 42: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 40 January 2015

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.

Page 43: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 41 January 2015

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 distributed to security staff on 12

th July 2014.

A familiarization session for all security involved personnel was held on 15

th 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.

Page 44: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 42 January 2015

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. An instruction for the ramp staff was displayed in the staff canteen on 10

th 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.

Page 45: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 43 January 2015

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: All respective personnel were instructed via internal order no 15, dated 22

nd 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 Quality Assurance department on 13

th 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.

Page 46: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 44 January 2015

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 23-6-1 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.

Page 47: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 45 January 2015

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.

Page 48: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 46 January 2015

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”.

Page 49: Isago q5 Auditee Manual Ed4 Jan2015

EXAMPLES OF ROOT CAUSES AND CORRECTIVE ACTIONS

ISAGO Q5 Auditee Manual Ed 4 47 January 2015

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.

Page 50: Isago q5 Auditee Manual Ed4 Jan2015

ISAGO Q5 Auditee Manual

ISAGO Q5 Auditee Manual Ed 4 48 January 2015

INTENTIONALLY LEFT BLANK

Page 51: Isago q5 Auditee Manual Ed4 Jan2015

ISBN 978-92-9252-475-3

www.iata.org