Supplementary Staff Instruction (SSI) No. SUR-001-M

Surveillance Procedures

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Issuing Office: Civil Aviation
Secretariat
Document No.: SSI SUR-001-M
File Classification No.: Z 5000-33 Issue No.: 04
RDIMS No.: 7080578 Effective Date: 2011-11-01

1.0  INTRODUCTION

1.1  Purpose

  1. The purpose of this Supplementary Staff Instruction (SSI) is to provide staff with additional administrative procedures to supplement the national standard detailed in Staff Instruction (SI) SUR-001.

1.2  Applicability

  1. This document is applicable to Transport Canada Civil Aviation Atlantic Region personnel. 

1.3  Description of Changes

  1. The following changes were introduced in this issue:
  • 2.3 added following definitions / abbreviations: ADO, process inspection

  • 4.1 (2)(g) “Branch” changed to TC Group

  • 4.1 (3) amount of time for on-site moved to 4.5 (2) Scheduling

  • 4.1 (4) added on-site phase; amount of time for on-site moved to 4.5 (2) Scheduling, and added reference to same; deleted “assessing”, covered elsewhere

  • 4.3 (1)(b) corrected manager’s title

  • 4.3 (i)(c)(iii) deleted reference to 5.1 (5), source / use unknown

  • 4.3 (1)(d) revised e-mail notification subject line; added reminder re bilingual internal notice, and reference to sample text

  • 4.3 (1)(f) changed approval for letter extension, from CA to ADO; added reference to document review guide

  • 4.3 (1)(f)(ii) deleted references to OSH questionnaire and best practices as this information is already contained in SI SUR-001

  • 4.3 (1)(f)(ii) (B) clarified terminology

  • 4.3 (1) Note 1 clarified term for agreement with CARs

  • 4.3 (1) Note 2 options to send letter restored

  • 4.3 (3)(b)Slide 3 clarified details for entering date

  • 4.5 (2)(a) multi-functional changed to multi-certificate

  • 4.5 (2)(b) amount of time team members are to block are now all addressed in one section; guidelines are no longer prescriptive, split is arbitrary but allows for more flexibility to customize for given situation

  • 4.5 (2)(b) Note clarified terminology; timeframe for report issuance moved to 5.0 (4)

  • 4.5 (2)(c) & (d) points combined into one

  • 4.6 revised for generality, instead of specifying just one of a number of documents

  • 5.0 (4)(c) “superintendent or manager” changed to TTL

  • 5.0 (4)(d) report timeframe relocated from 4.5 (2)(b) Note; CA changed to ADO

  • 6.0 (1) “regional manager” changed to TTL

  • 6.0 (2) “individual inspector” changed to TTL; “combined (i.e. multi-divisional) PVI” changed to combined-certificate PVI; “PVIM’s division manager” changed to ADO

  • 7.2 (1)(h) step added to enter PVI score into NACIS

  • 7.2 (1)(i) “superintendent” changed to TTL

  • 7.1 (2)(c) section revised so that related documents including the report are unclassified

  • 8.0 (5) Regional Manager, Aircraft Certification” changed to TTL, Engineering “Regional Sup’t., Safety Oversight Certification” & “Regional Manager, General Aviation” changed to applicable Service Team Lead

  • 9.0 to 9.3 added new sections related to process inspections

  • 10.0 new appendices added – W, X, and Y

2.0  REFERENCES AND REQUIREMENTS

2.1  Reference Documents

  1. It is intended that the following reference materials be used in conjunction with this document. The latest version of these documents are available from the Documentation Framework on the Transport Canada, Civil Aviation intranet.

    1. Staff Instruction (SI) SUR-001 - Surveillance Procedures

    2. Staff Instruction (SI) SUR-002 - Enhanced Monitoring

    3. Inspection and Audit Manual (IAM), TP 38608

    4. Maintenance Schedule, TP 13904

    5. Small Operator Maintenance Control Manual (SOMCM)

    6. Travel Directive

2.2  Cancelled Documents

  1. Not applicable.

2.3  Definitions and Abbreviations

  1. The following definitions and abbreviations are used in this document:

    1. ADO – Associate Director, Operations

    2. AMO – Approved Maintenance Organization

    3. CAP – Corrective Action Plan

    4. COM – Company Operations Manual

    5. FTU – Flight Training Unit

    6. IAM – Inspection and Audit Manual

    7. NASD – National Aerodrome Safety Database

    8. PI –Principal Inspector

    9. Process Inspection (PI) – an in-depth review of the processes utilised to produce an output.  No score is assigned.

    10. Program Validation Inspection (PVI) – a process comprised of a documentation review and an on-site review of one or more components of a Safety Management System or other regulated areas of a certificate holder.  A score is assigned.  PVI's are conducted on a routine schedule and will use risk factors to adjust the frequency as necessary.

    11. Program Validation Inspection Manager (PVIM) – means the person appointed by the Convening Authority to conduct the program validation inspection.

    12. QA – Quality Assurance

    13. SI – Staff Instruction

    14. SOP – Standard Operating Procedures

    15. SSI – Supplementary Staff Instruction

    16. TTL – Technical Team Lead

3.0  BACKGROUND

  1. This SSI was created to provide staff with additional administrative procedures to supplement the national standard detailed in SI SUR-001.

4.0  PROGRAM VALIDATION INSPECTION PROCEDURES 

4.1 Planning and Scheduling

  1. The Convening Authority will:

    1. Plan the surveillance activities

    2. Ensure the “Original Planned Date” for the PVI is entered into NACIS

    3. Determine the number of inspectors required

    4. Assign an inspector to be the PVI manager

  2. The PVI Manager will:

    1. Schedule the PVI

    2. Select team member(s)

    3. Conduct the PVI preparation and ensure it is completed by the PVI team members

    4. Ensure the PVI date is planned in NACIS per the following:

      Main NACIS Screen

    5. Select appropriate company

    6. Select “Audit / Inspection Tracking” tab

    7. Highlight and select applicable TC Group

      Select “Planned” tab

    8. Confirm Inspection Box selected

    9. Under “Type” select Program Validation Inspection

    10. Planned Date -  update “Planned Date”

    11. Planned Order – as to risk (low, medium, high), leave at default “Medium”

    12. Planned ARASS number -  confirm correct

    13. Fill in Planned Resources & Cost breakdowns, as applicable (optional)

    14. Save all updates

      Select “Contacts” tab

    15. Convening Authority -  confirm appropriate name

    16. Audit Manager -  confirm appropriate name

    17. Confirm Office of Primary Interest

    18. CAP Inspector - select PI or other person assigned

    19. Follow-up Inspector - select PI or other person assigned

    20. Save all updates

  3. The PVI Manager shall:

    1. Send an appointment request to the team member(s), using “MS OUTLOOK Calendar” indicating the company name and planned date.

      Note: Additional time on site may be required for larger, complex companies.

    2. Start the PVI Process Confirmation Checksheet.

    3. Ensure all team members track their actual time spent during each of the 3 phases of the PVI process, including travel time.

  4. The PVI team member(s) shall block out time in their MS Outlook Calendar for pre-PVI (preparation), on-site PVI, and post-PVI activities.  See 4.5 (2) for guidelines on scheduling times.

4.2 Rescheduling or Canceling PVI

  1. Rescheduling of a PVI refers to changing the planned date and rescheduling it within the same fiscal year.  Cancelling of a PVI refers to changing the date or cancelling the activity so it will not be completed within the fiscal year in which it was planned.

  2. If the need arises to reschedule a planned PVI, the PVI manager will coordinate with the team members, update their MS Outlook Calendar and advise the CA of the new date.  The advisory should be by e-mail and saved in rdims, and a note should also be made in NACIS.

  3. If the need arises to cancel a planned PVI, the PVI manager will:

    1. Complete an entry in the Risk Indicators Assessment Database (if applicable)

    2. Consult with the CA

    3. Provide justification for the cancellation which may include, but is not limited to the following circumstances:

      1. Certificate suspension

      2. Certificate action occurring

      3. Lack of resources

      4. Other

    4. Obtain CA concurrence
  4. Once concurrence from the CA has been received, the PVI is considered cancelled and the PVI manager will advise the PVI team member(s) and PI if applicable, and update MS Outlook.

  5. PVI manager will document the justification for cancellation of a PVI by entering the justification in NACIS and saving the information in the Risk Indicators Assessment Database.

    1. NACIS:

      1. Open the applicable “Reference” number for the activity planned

      2. Enter the justification in the Notes section of the Audit/Inspection Planned Tab

      3. Change the “Status” flag to “Cancelled”

Note:  If cancelling a PVI, do not delete the record from NACIS.

4.3 Notification

  1. The PVI manager is responsible to:

    1. Contact the PI to advise of the upcoming PVI and to obtain information on the company when required.
    2. Contact the Regional Manager, Aviation Enforcement and request a records check regarding any issues or enforcement actions (historical or on-going) applicable to the company or key personnel since the last oversight activity.
    3. Contact the company key personnel by phone, fax or email to:

      1. Notify the company of intent to perform a PVI;
      2. Confirm the date. If the date is different than the planned date in NACIS, revise NACIS and MS Outlook Calendar as applicable;
      3. Confirm their preference for further communications regarding the PVI, e.g. by fax, e-mail or post;
      4. Arrange for site facilities and equipment as required;
      5. Identify and request missing or incomplete documentation from the certificate holder to be forwarded to the TCC, e.g. documents incorporated by reference (SOPs, Procedures Manuals, Small Operator Maintenance Control Manual, QA Checklists, etc.); and
      6. Request pertinent company records be made available on-site during the PVI.
    4. Send an e-mail to MA All, with the subject line: Program Validation Inspection / Inspection de validation de programme – [COMPANY NAME] – [DATE]   E-mails to MA All should be in English and French, a sample bilingual text is available in Appendix Z.
    5. Prepare the PVI notification letter using one of the templates in Appendix B, which contain the minimum required content.  Items identified in the notification letter as optional may be included when required.
    6. The letter is to be sent to the company’s Accountable Executive.  A letter sent without minimum 6 weeks notice requires approval of the ADO.  It should include  a copy of the documentation review guide (or similar document) to be completed by the certificate holder prior to the documentation review, and the due date for its return, e.g.:

      1. For an Operational Control PVI on a Part 7 Certificate Holder - the appropriate COM Certification Form for the operation (Appendix D1 to D3)  
      2. For an Operational Control PVI on a Part 7 Certificate Holder with passenger-carrying authority  - the appropriate Safety Features Card Certification Form for the operation (Appendix E1 to E3);
      3. For a maintenance Quality Assurance PVI of Part 4, 5, or 7 certificate holder –

        1. appropriate Document Review Guide (contained in worksheet, see Appendices)
        2. Document Review Guide for the Performance Rules Worksheet (Appendix R) for Part 5
      4. For a PVI on a Part 3 Certificate Holder – the AOM Document Review Guide (Appendix V)
      5. For a PVI on a Part 4 Certificate Holder – the FTU COM Certification Form (Appendix D4)

      Notes:

      1. The notification letter may also be cc’ed to other company representatives if required. e.g.  Operations Manager, Person Responsible for Maintenance, etc.

      2. The PVI notification letter and attachments may be sent by mail e-mail, or facsimile.

  2. If the required documents are not returned to Transport Canada within the specified timeframe, refer to SI SUR-001, Section 14.4 for instructions.
  3. The PVI manager will update NACIS with the PVI notification letter sent date by:

    1. Select “Actual” tab
    2. CA Letter Sent – fill in date letter was sent
    3. Save; confirm status changes from Planned to Scheduled.
  4. Enter the rdims number of the PVI notification letter on the Process Confirmation Checksheet, item no. 3.  (Appendix A)

4.4 Team Selection

  1. SI SUR-001 contains guidance on team selection and qualifications.

  2. It is recommended that a minimum of two people be assigned to each PVI (a PVI manager and a team member).

  3. The PVI manager duties should be assigned to someone other than the PI(s), however wherever possible it is recommended that the PI(s) be a team member.

4.5 PVI Plan

  1. Travel

    1. The PVI manager is responsible to ensure:

      1. Transportation and accommodation arrangements are made in accordance with the Travel Directive.

      2. Tools and equipment that may be required during the PVI are arranged for.

        Note: Budget approval rests with the TTL, and the PVIM may be asked to provide information to assist in the budget deliberations.

    2. PVI team member(s) is responsible to ensure that flight or train transportation is booked through Travel AcXess Voyage.
    3. PVI manager and team member(s) are responsible to ensure appropriate travel time is planned for each phase of the PVI.
  2. Scheduling

    1. Preparation time should be planned far enough in advance of the on-site activity to accommodate for any scheduling conflicts or issues that may disrupt the preparation.  Complex and multi-certificate PVIs may require additional time for pre, on-site and post PVI activities.

      Note:  It is recommended that the preparation be scheduled for 1-2 weeks prior to the date of the on-site activities.

    2. Time is to be scheduled in MS Outlook Calendar in accordance with the following general guidelines: for smaller PVI’s – 2 days pre-inspection, 1-2 days on-site, and 1 day post-inspection; for larger PVI’s – 3 days pre-inspection, 3-4 days on-site, 2 days post-inspection    These are suggested timelines and should be adjusted as necessary based on factors such as size, complexity, number of certificates, resources etc.

      Note: When scheduling post PVI activities factor in the time required to review and analyze the results.

    3. If preparation is not completed, the PVI manager must advise the CA, and the PVI must be re-scheduled or cancelled.

4.6 Preliminary Documentation Review

  1. Upon receipt of the company’s completed  documents,  the PVI manager shall:

    1. Save the document(s) into rdims using the applicable TCCA protocols
      Note: If the document(s) are required for the documentation review, retain a copy prior to sending to Information Management for scanning.

    2. Enter the rdims number(s) on the Process Confirmation Check sheet, item no. 7

    3. Request the specialist(s) review the supplemental documents if they are not part of the PVI team.

  2. PVI manager shall print the Pre-Audit Report from NACIS by:

    Main Screen

    1. Operations:  Select CBA>OC>
      Maintenance: Select AO>
      General Aviation: Select GA>OC

    2. Select Reports

    3. Select Pre-Audit  - enter company file number or click box to allow you to enter the company name

    4. Ensure the correct company criteria are shown and click OK.

  3. PVI team shall review the following sections of the pre-audit report for accuracy as compared to Transport Canada databases and the approved company manuals:
    1. Company Information Section

    2. Applicable Certificate Information Section

  4. When review is complete, the PVI manager shall:
    1. Notify the PI(s) of any updates required

    2. Indicate your name in the section at the bottom of the last page of the report

    3. Retain pre-audit report as part of the PVI records.

  5. PVI team shall review the following information as applicable to the company’s certificate(s) including:

    Mandatory Items:
    1. Verify legal name and trade name with company files, manuals and NACIS

    2. Identify company scope

    3. Approved company manuals or applicable section, and incorporated by reference documents;

    4. Company file review - rdims and/or hard copy

    5. Previous audit / inspection / surveillance reports

    6. Exemptions if applicable

      Optional Items:

    7. Aircraft files

    8. Airworthiness Directives

    9. Civil Aviation Daily Occurrence Reports (CADORs)

    10. If special processes exist, review process specifications e.g. NDT

    11. Personnel licence databases to confirm validity of company personnel qualifications and licences

    12. Continuing Airworthiness Web Information System (CAWIS)

    13. Type Certificates

    14. Transport Canada data bases (e.g. CCARCs, FTAE, AMES, etc.)

    15. Company web page, if applicable

    16. Approved Check Pilot Information from NACIS and FTAE Statistics, as applicable.

  6. PVI manager shall consult with the CA:
    1. If issues arise which may require parallel finding(s) or observation(s); and/or,

    2. If additional areas are considered for inclusion in the PVI.  IAM check sheets are available as a guideline for additional areas.

4.7 Entry Meeting

  1. PVI manager will convene an entry meeting with company key personnel and the PVI team. Appendix F contains an entry meeting sample guide, detailing discussion points. 

    Note:   Let the company decide on appropriate personnel to attend.
  2. Record date, time, and attendees, including Transport Canada personnel, in the space provided on the entry meeting form, and retain as part of the final PVI package. 

4.8 Use of PVI Worksheets

  1. In the case of an AMO, stand-alone or with multiple certificates, the Performance Rules Worksheet, Appendix R, is to be used in conjunction with the applicable PVI Quality Program Worksheet. 

  2. In the case of an operator who has adopted the Small Operator Maintenance Control Manual (SOMCM), the document review will consist of a familiarization review of the QA program portion of the document, verification of the tombstone data (e.g. type and number of aircraft operated, address etc) revision status and a review of the company’s QA checklists and any company developed procedures for the QA program.

Note:  All other items remain applicable for those who have adopted the SOMCM

4.9 Exit Meeting

  1. PVI manager shall conduct an exit meeting with key company personnel. Appendix G contains a sample exit briefing.

    Note: Let the company decide on appropriate personnel to attend

  2. Record the date, time, and attendees, including Transport Canada personnel, in the space provided on the exit meeting form, and relevant discussion points pertaining to issues identified during the PVI on the form or incorporated attachment, and retain as part of the final PVI package.

5.0  PVI REPORT

  1. The PVI report can follow a similar format as an Assessment report, or can consist of the standardized letter format with the non-conformance findings attached per Appendices I and J.

  2. The completed worksheets are not to be sent out to the companies with the PVI report.

  3. The letter can be signed by either the CA or the PVI manager at the discretion of the CA.

  4. The PVI manager shall:

    1. Complete the letter and the findings to compile the PVI report.

    2. Ensure that the report clearly states the results of the validation similar to an executive summary and that it includes corrective action information and enforcement information where applicable;

      Note:  Executive summary details are contained in SI-SUR-001 Section 5.3.2.1.1. Do not include subjective statements, suggestions or recommendations in the report.

    3. Prior to sending the PVI report to the company, for a single-certificate PVI send the report to the Technical Team Lead  for review, and for a combined PVI send it to the CA.

    4. In accordance with SI SUR-001, the PVI report must be sent to the certificate holder within 30 days from the last day of the on-site portion.  If an extension to the time limit for sending out the report is granted by the ADO, it will be recorded in the Notes section of the report tab in NACIS for the activity and the report due date will be updated.

    5. Use a method of delivery that provides confirmation of receipt. When the report is hand delivered, ensure to record it on the PVI Process Confirmation Check sheet;

    6. Save the PVI Report into rdims; Ref: 7.1 and record the rdims number on the Process Confirmation Check sheet; and,

    7. Forward the rdims link via email to the CA and PI(s), if the PI is other than PVI manager, upon completion and delivery to the company.

6.0  RESPONSIBILITIES

  1. Technical Team Lead – responsible for ensuring the financial and human resources are made available to accomplish the tasks.

  2. Convening Authority (CA) – The CA on a single-certificate PVI is the Technical Team Lead; the CA for a combined-certificate PVI (including 705) is the Associate Director, Operations.  (see also SI SUR-001, s. 18.1)

  3. Program Validation Inspection Manager (PVIM) – responsible for the overall management of the PVI process in accordance with this SSI. (see also SUR-001, s. 18.2)

  4. Team Member – responsible for conducting the PVI in accordance with this SSI.  (see also SUR-001, s. 18.4)

  5. Principal Inspector (PI) – responsible for providing information to the PVIM when requested.

 

7.0  INFORMATION MANAGEMENT

7.1 Records Management

  1. RDIMS - The PVI manager shall save into rdims all documents that are created for the PVI process.

    Note: Follow rdims naming convention, # 1514089

  2. The following protocols are to be followed when profiling PVI documents:

    1. Name – enter "Program Validation Inspection (i.e. Report, Notification Letter, Worksheets, etc.) – ABC Airlines - 25 May 2003"

    2. Descriptionoptional

    3. Security – select 1 (Unclassified) for the PVI report and all other PVI documents

    4. Author and OPI – ensure the proper defaults are selected

    5. Access – The PVI Manager will ensure that MA has Normal access rightsand AAR Civil Aviation has Read Only access rights.  If the access rights need to be modified, press the “Edit” button and follow the steps below:

      1. Double Click on "Groups"; Highlight MA Civil Aviation – Click on "Add"; In the "Current Trustees Box" Highlight MA Civil Aviation - Access Rights Select "Normal"

      2. Double Click on "Groups"; Highlight AAR/AAX Civil Aviation - Click on "Add"; In the "Current Trustees Box" Highlight AAR/AAX Civil Aviation - Access Rights Select "Read Only";

    6. Classification – Press the “Search” button to find the appropriate 5015/5258/5016/5151-XXXX-17 file classification
    7. Final Document – Report sent will be saved as a “Final Document”.

      Prior to selecting “Final Document”, “Original Signed by XXX” shall be included in the signature block area. When the “Final Document” box is selected, it is considered signed by the originator.

  3. Hard Copy Files – The PVI manager shall ensure all hard copy supporting documentation that is not saved or scanned into rdims, is placed in the company paper files. 

Note:

  1. Approved Training Organizations do not have –17 files.  Please use 5016-XXXX

  2. The following file classifications are for reference purposes only:

    Airworthiness – 5015-XXXX-17
    Flight Operations – 5258-XXXX-17 
    Combined
    Airworthiness and Flight Operations – 5258-XXXX-17
    General Aviation – 5811-XXXX –17        
    Aerodromes and Air Navigation – 5151-XXX –17

7.2 NACIS Updates

1. The PVI manager shall update NACIS with the information below, within 10 working days of sending the PVI report:

Select “Actual” tab

a. Entry meeting date and Exit meeting date

b. Enter Actual ARASS field as appropriate

c. “Actual Resources and Cost breakdown” fields as applicable;

Select “Findings” tab

d. Select “Add” button and enter Finding details as required by the fields in NACIS Select

“Audit Report” tab

e. Actual sent date.  Accept default date for CAP due

f. Reference rdims document number in “Notes” section

g. Enter score for component or technical area in “Notes” section

Select “CAP” tab

h. Confirm the “Due date” field has been populated.

i. CAP Inspector – PI or person assigned by TTL

j. Refer to Tombstone Data section 

k. Confirm the Status block shows “CAP Due” 

2. The PVI manager shall ensure NACIS is updated with the following:

a. Select “Report” tab

i. Actual sent Date

7.3 NASD

  1. For PVI's conducted on CAR 302 certificate holders, the PVI Manager will create an entry in NASD, by generating a PVI 'checklist'.  This checklist provides a place to input PVI notes, and link related rdims documents (report, interview records, etc.) to that entry in NASD.

7.4 Risk Indicator Assessment Database

  1. The PVI Manager shall update the Risk Indicator Assessment Database where applicablewithin 10 working days of sending the report. Information pertaining to the database use will be incorporated once regional procedures have been established.

7.5 ARASS

  1. The PVI manager is responsible for claiming the applicable PVI completion task in ARASS.

    Note:  Only the PVI manager should claim the PVI completion task.

  2. The PVI team members will claim the actual days (7.5 hours per day) spent on PVI activities. e.g. preparation, on-site, post PVI activities, and travel time.

  3. The PVI manager and team members are responsible for claiming any aircraft and/or aeronautical product inspections and/or monitoring of training, which occurred during the on-site activities using the applicable ARASS tasks.

7.6 PVI Process Confirmation Checklist

  1. Each team member will provide the PVI manager with their actual time spent during each of the 3 phases of the PVI process, including travel time. 

  2. The PVI manager will compile the hours spent during the PVI and record in the applicable area of the Process Confirmation Checksheet after each phase.

  3. The PVI manager will note the date the report was sent on the PVI Process Confirmation Checksheet.

  4. The PVI manager shall review the PVI Process Confirmation Checksheet for accuracy, enter their name, date the checksheet where indicated and forward to the CA.

  5. The CA shall review the PVI Process Confirmation Checksheet, enter their name, and date where indicated.

  6. The PVI Process Confirmation Checksheet shall be saved in the hard copy file or scanned into rdims (depending on TCCA protocol) and marked final.

8.0 Process Inspection Procedures

8.1 General

  1. In addition to being scheduled as a routine activity or in response to risk indicators, as detailed in SI SUR-001, a process inspection can also be conducted in response to an event.

  2. A report is not normally required.  Findings can be documented on the Finding Form, and accompanied by a cover letter (see sample at Appendix X).  Include a blank corrective action form for the company’s response to the findings.

  3. The results of the inspection will be forwarded to the TTL, who will forward to the ADO as required.

8.2 Information Management

  1. For each process inspection, a Process Inspection Coversheet is created (see Appendix W for template).

    1. For consistency, follow this naming convention: PROCESS INSPECTION COVERSHEET – NAME OF COMPANY – 27 JULY 2011

    2. The date shall be the first date of on-site inspection, for both the rdims name, and for the date field on the coversheet.

  2. The inspector who convened the process inspection shall ensure that all documents created for and related to the process inspection are saved into rdims in the appropriate company file.  All process inspections will comprise a company documentation review, other documents may include, but are not limited to:

    1. process inspection template

    2. process flow map

    3. interview plan

    4. sampling plan

    5. interview record

    6. sampling record

    7. inspection report (e.g. base inspection, ramp inspection, training monitor, etc.)

    8. memo to file

    9. finding

    10. letter to company

    11. corrective action plan

8.3 NACIS

  1. The inspector who convened the process inspection shall update NACIS with the information below, within 10 days of sending the letter to the company, or within 10 days of completing the inspection if no findings.

    Select “Audit / Inspection Tracking” tab

    1. Select “New” button

    2. Select mandatory inspection over audit

    3. Choose process Inspection from drop-down list for “Type”

      Select “Planned” tab

    4. Original planned date - enter planned first date of on-site inspection

      Select “Actual” tab

    5. Audit manager – enter name of inspector convening the inspection

    6. CA letter sent – enter first date of on-site inspection

    7. Entry meeting date – enter date of entry meeting if applicable, if no entry meeting was held, enter first date of on-site inspection

    8. Exit meeting date – enter date of exit meeting if applicable, if no exit meeting held, enter last date of on-site inspection

      Select “Findings” tab

    9. Select “Add” button and enter finding details, as required by form fields

      Select “Audit Report” tab

    10. Actual date sent – enter date letter and findings were sent to company.  If nil findings, or if detection notice sent, make comments in “Notes” field and enter the first date of on-site inspection

    11. CA closing letter sent – enter date follow-up is complete.  If nil findings, or if detection notice was sent, enter the date of the exit meeting, or last date of on-site inspection

      Select “CAP” tab

    12. Due date – enter due date for CAP, as detailed in letter

    13. Received date – enter date CAP received

      Select “Follow-up” tab

    14. Indicate whether follow-up is required or not; if yes, enter Proposed Follow-up Date, and Completed Date once follow-up is complete

9.0 Communications with other Divisions

  1. Other Civil Aviation divisions should be advised when unsafe practices or regulatory violations are discovered or when we have information that could impact approvals. The following communication protocols are to be followed:

    1. Aviation Enforcement – The PVI team may consult with Aviation Enforcement if required, by telephone.  Documentation requiring review by Aviation Enforcement should be directed to the Regional Manager, Aviation Enforcement, using standard routing protocols.

    2.  Airworthiness – When the PVI team determines it is necessary to consult on airworthiness matters during the program validation inspection, the company's Principal Airworthiness Inspector is to be contacted by telephone.  When it has been determined that the observed unsafe practice or regulatory violation is valid and could affect the Approved Maintenance Organization Certificate, the company's Principal Airworthiness Inspector is to be notified by email with a cc: copy to the convening authority. 

    3. Flight Operations – When the PVI Team determines it is necessary to consult on an operational matter during the program validation inspection, the company's Principal Operations Inspector (POI) is to be contacted by telephone.  When it has been determined that the observed unsafe practice or regulatory violation is valid and could affect the Operating Certificate, the company's POI is to be notified by email with a cc: copy to the Convening Authority. 

    4. System Safety – When the PVI Team observes unsafe practices being carried out that are not Civil Aviation regulatory infractions, the Convening Authority and regional safety officer related to maintenance should be notified by email.

    5. Aircraft Certification – When the PVI Team  determines it is necessary to consult on matters related to technical approvals held by the company during the program validation inspection, all matters should be directed to the Technical Team Lead, Engineering . Issues requiring Aircraft Certification follow up are to be e-mailed to the Convening Authority and to the Technical Team Lead, Engineering.

    6. General Aviation – When the PVI Team determines it is necessary to consult on matters related to licensing, all matters should be directed by e-mail to the applicable Service Team Lead, with copies to the Convening Authority.

    7. HQ Ottawa – Issues that may impact on foreign approvals/acceptance should be communicated to HQ Ottawa, Standards and Procedures with a copy to the convening authority. However, PVI team members should try to resolve issues affecting foreign approvals whenever possible.

10.0 Document History

  1. Staff Instruction (SI) SUR-001 M Issue 01 – Program Validation Inspections, RDIMS 5335627 (E), 5335633 (F), dated 2009-10-01

  2. Staff Instruction (SI) SUR-001 M Issue 02 – Program Validation Inspections, RDIMS 5906636 (E),5925636 (F), dated 2010-10-01

  3. Staff Instruction (SI) SUR-001 M Issue 03 – Program Validation Inspections, RDIMS 6228662 (E), 6233810 (F), dated 2011-01-04

11.0 Appendices

*A document review guide is included at the end of the worksheets that are marked with an asterisk.

APPENDICES RDIMS #
Program Validation Process Confirmation Checksheet Appendix A 5177666
Program Validation Notification Letter Combined
CBA only
Appendix B1
Appendix B2
5219345
5219297
Health and Safety Questionnaire Appendix C 5271882
COM Certification Form
703 Fixed Wing
703 Rotary Wing
704 Fixed Wing
406 FTU
Appendix D1
Appendix D2
Appendix D3
Appendix D4
5308968
5309012
5308993
6380978
Safety Features Card Certification Form 703 Fixed Wing
703 Rotary Wing
704 Fixed Wing
Appendix E1
Appendix E2
Appendix E3
4422076
4422105
4422146
Entry Meeting Notes Appendix F 4191965
Exit Meeting Notes Appendix G 4192007
Evidence Log Appendix H 5309103
Program Validation Report – with findings Appendix I 3977939
Program Validation Report – NIL findings Appendix J 3977946
703/704 Operations Worksheet Appendix K 4757558
Dangerous Goods Operations Worksheet Appendix L 4768087
Air Operator Maintenance Worksheet*     Appendix M 5309190
Approved Maintenance Organization Worksheet* Appendix N 5309201
Air Operator/Approved Maintenance Organization Worksheet* Appendix O 5309405
Flight Training Unit Maintenance Worksheet* Appendix P 5309423
Flight Training Unit/Approved Maintenance Organization Worksheet* Appendix Q 5309451
Performance Rules 571.02 Maintenance Worksheet* Appendix R 5309463
Manufacturers Worksheet* Appendix S 5309466
Distributors Worksheet Appendix T 5309468
Approved Training Organization Maintenance Worksheet Appendix U 5309470
Document Review Guide - Airport Operations Manual Appendix V 6382031
Process Inspection Coversheet Appendix W 6753524
Sample Letter – Process Inspection with Findings Appendix X 7007157
Template - Document Review – Process Inspection Appendix Y 6902954
Sample Notification of PVI (internal) Appendix Z 6902895
SMS Elements, Tables 1.1 to 6.1 refer to SI SUR-001, Appendix A
Program Validation Inspection Worksheet – CAR 302 refer to SI SUR-001, Appendix A
Program Validation Inspection Worksheet – CAR 406 refer to SI SUR-001, Appendix A
Program Validation Inspection Worksheet – CAR 703/704 refer to SI SUR-001, Appendix A
Program Validation Inspection Worksheet – EASA Supplement refer to SI SUR-001, Appendix A
On-Site Review Plan Template refer to SI SUR-001, Appendix A
Assessment Report Template refer to SI SUR-001, Appendix A
Letter of Acknowledgment refer to SI SUR-001, Appendix A
Process Inspection Templates refer to SI SUR-001, Appendix A

12.0 Contact

For more information, please contact the:
Regional Coordinator, Safety Management Systems - Civil Aviation Atlantic Region (MA)
Phone:    902-873-2814
Facsimile:902-873-1379

Suggestions for amendment to this document are invited, and should be submitted via the following e-mail address:
E-mail:    CAIRS_ATL@tc.gc.ca

Original signed by

Keith Whalen  
A/Regional Director
Civil Aviation

Transport Canada documents or intranet pages mentioned in this document are available upon request.