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

Surveillance Procedures

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Issuing Office: Civil Aviation Ontario Region
Activity Area: Oversight SSI No.: SUR-001-P
File No.: P 5000-1 Issue No: 02
RDIMS No.: 3977901 v8 Effective Date: 2010-06-26

1.0  INTRODUCTION

1.1  Purpose

The purpose of this Supplementary Staff Instruction (SSI) is to ensure a consistent approach in conducting program validation inspections and process inspections and to provide staff with the regional procedures that supplement the national standard detailed in Staff Instruction (SI) SUR-001.

1.2  Applicability

This document is applicable to Transport Canada Civil Aviation Ontario Region personnel. This procedure starts when the decision to conduct a program validation inspection or process inspection has been made and ends when the activity has been reported and recorded.

1.3  Description of Changes

This SSI has been significantly updated to incorporate recent changes to the Surveillance Procedures SI-SUR-001 as well as updates based on recommendations received since last release. Changes have been identified with right hand change bars for your reference. The key changes to the document are:

  1. Title changed from Program Validation Inspection SSI to Surveillance Procedures SSI

  2. The term oversight has been removed from the document and replaced with surveillance

  3. The term company has been replaced in some instances throughout the document with enterprise

  4. Incorporation of Process Inspection procedures

  5. Addition of Operational Support Personnel Activities

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2.0  REFERENCES AND REQUIREMENTS

2.1  Reference Documents

It is intended that the following reference materials be used in conjunction with this document. Obtain the latest version of headquarters documents from the Documentation Framework available through the green triangle on the 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

  7. Civil Aviation Document (CAD) CAD SUR-008 - Surveillance Policy

  8. Confirmation Request Form – RDIMS #1814040

  9. Corrective Action Plan 2 Page form – RDIMS #1814391

  10. Parallel Finding Form – RDIMS # 1814056

  11. Parallel Observation Form – RDIMS # 1814062

  12. Safety Features Card Certification Forms: 703-Fixed Wing RDIMS #4422076; 703 Rotary Wing RDIMS #4422105; and 704 Fixed Wing RDIMS #4422146

  13. Operations 703/704 Worksheet RDIMS #4757558

  14. Airport/Heliport Operator Worksheet RDIMS #4422273

  15. Air Operator Maintenance Worksheet RDIMS #3977974

  16. Approved Maintenance Organization Worksheet RDIMS #3977979

  17. Air Operator/Approved Maintenance Organization Worksheet RDIMS #3977984

  18. Flight Training Unit Maintenance Worksheet RDIMS #3977990

  19. Flight Training Unit/Approved Maintenance Organization Worksheet RDIMS #3977996

  20. Performance Rules 571.02 Maintenance Worksheet RDIMS #3977998

  21. Manufacturers Worksheet RDIMS #3978003

  22. Distributors Worksheet RDIMS #3978007

  23. Approved Training Organization Maintenance Worksheet RDIMS #3978010

  24. Dangerous Goods Worksheet RDIMS #5456060

  25. Supplementary Staff Instruction (SSI) SUR-008-P Oversight Planning RDIMS #3815074

  26. COM Certification Form 703 Rotary Wing RDIMS #3977915

aa. European Aviation Safety Agency (EASA) Part 145 Approval Worksheet RDIMS #5290193

bb. Air Traffic Service Operator Worksheet RDIMS #4422373

cc. Flight Training Unit Operations Worksheet RDIMS #5954086

2.2  Cancelled Documents

Not applicable.

2.3  Definitions and Abbreviations

The following definitions and abbreviations are used in this document:

  1. CAP – Corrective Action Plan

  2. COM- Company Operations Manual

  3. Convening Authority (CA) – the individual responsible for authorizing and overseeing the surveillance activity (PVI or PI) e.g. Superintendent, Operations Manager - East/West

  4. Document - written, printed, or electronic matter that provides information.

  5. Finding - means a non-conformance to a regulatory requirement.

  6. ICA – Instructions for Continued Airworthiness

  7. Interview – a discussion to obtain information.

  8. Key personnel – the main individuals within an enterprise responsible for the running of the enterprise and/or the operational/maintenance control system (Person Responsible for Maintenance, Operations Manager, etc.).

  9. Observation - means the outcomes obtained during documentation or on-site reviews that are used to confirm a specific requirement of a system, component or element.

  10. Ops Support – Operational Support Personnel

  11. PI – Principle Inspector

  12. Planning – the activity of determining when and who will do something.

  13. Process Inspection - means an in depth review of the processes utilised to produce an output. A score is not assigned.

  14. Process Inspection Lead – the individual conducting the process inspection and or leading a team to conduct the process inspection.

  15. Program Validation Inspection (PVI) – a focused review of one or more components of an organization or Safety Management System. A score is assigned.

  16. Program Validation Inspection Manager (PVIM) - the individual, designated by the Convening Authority, responsible for the conduct of the program validation inspection.

  17. Random Sampling – a selection method that allows each item to have an equal chance of being chosen.

  18. QA – Quality Assurance

  19. Record - evidence or information constituting an account of something that has occurred, been said, etc.

  20. Rules of Evidence – the process of collecting and safekeeping items (documents, photographs, parts etc.) that may be needed for an enforcement action.

  21. SI – Staff Instruction

  22. SSI – Supplementary Staff Instruction

  23. Scheduling – the task of establishing the date, time and location of the activity.

  24. Supporting documentation – any item(s) (photocopies, photographs, parts, documents etc.) that corroborates a finding of non-conformance.

  25. Surveillance – means all activities directly related to a certificate holder’s compliance with the applicable regulations and standards including, but not limited to, assessments, validation inspections, process inspections, audits, company visits (formal or informal), ramp, cockpit, cabin or aircraft inspections, facility or shop visits, review and approval of company documentation, correspondence by any means, as well as any other activity that could be used to gather information related to a certificate issued by the Minister.

  26. Team Member – the individual appointed by the CA or PVI Manager to participate in a surveillance activity. This included PVI, Process Inspection, etc.

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3.0  BACKGROUND

The primary means used within Civil Aviation to conduct routine surveillance has been various types of inspections. A shift in surveillance policy has driven the program to focus on measuring an organization’s ability to hold itself accountable for its own compliance. It is Transport Canada’s role to determine if the system is compliant with the regulatory requirements and is being used by the enterprise and if the system processes are effective. It is not Transport Canada’s role to find every example of non-compliance that may exist within a enterprise’s system(s).

This SSI was created to harmonize the surveillance program in Civil Aviation, Ontario Region with the policy and instructions stipulated in the National Staff Instruction “Surveillance Procedures” SUR-001 (SI-SUR-001).

This SSI fulfills the SI-SUR-001 requirements by establishing the standard to be used for PVI and process inspection planning, the assigning of responsibilities, establishing the administration process, and providing a recording method for consistent delivery of the program.

4.0  RESPONSIBILITIES

Operations Manager - East/West – ensuring the financial and human resources are made available to accomplish the tasks

Convening Authority (CA) – responsible for authorizing, assigning resources and developing and monitoring the surveillance plan, and ensuring compliance with this SSI. The CA is usually the Superintendent.

Operational Support Person (Ops Support) – responsible for conducting the administrative activities in support of the PVI or process inspection in accordance with this SSI when requested by the Convening Authority.

Process Inspection Lead – responsible for the overall management of the process inspection in accordance with this SSI, including participating in the process inspection and managing a team and writing the report if required.

Program Validation Manager (PVIM) – responsible for the overall management of the PVI process in accordance with this SSI, including managing the team, writing the report and participating in the PVI.

Principle Inspector (PI) – responsible for providing information to the PVI Manager or Process Inspection Lead when requested.

Team Member– responsible for conducting the PVI or process inspection in accordance with this SSI.

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5.0  PRE-INSPECTION

5.1  Planning and Scheduling

  1. The Convening Authority (Superintendent) will plan and schedule the PVI and or Process Inspection in accordance with Oversight Planning Process SSI-SUR-008, RDIMS #3815074.

    Note:

    1. It is recommended that a minimum of two people be assigned to each PVI (a PVI Manager and a Team Member).

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

    3. It is recommended that the PI be a member of the PVI team. However, when possible, the PVI Manager duties should be assigned to someone other than PI.

  2. The Ops Support Person may be tasked with duties in support of surveillance activities at the discretion of the CA. Guidance for the Ops Support is available in Appendix J.
  3. The PVI Manager or Process Inspection Lead will:

    1. Schedule the surveillance activity (PVI or Process Inspection):

    2. Select team member(s);

    3. Conduct the preparation and ensure it is completed by the team member(s); and

  4. The PVI Manager or Process Inspection Lead will ensure the date of the surveillance activity is planned in NACIS per the following:

    • Main NACIS

    • a. Screen Select appropriate company

    • b. Select audit and inspection tracking tab

    • c. Highlight and select applicable Branch

    • Select “Planned Tab”

    • d. Confirm Mandatory Inspection Box selected

    • e. Under “Type” confirm “Program Validation Inspection” or “Process Inspection”

    • f. Planned date: Update “planned date”

    • g.Planned Order – risk (low, medium, high) leave at default “Medium”

    • h. Fill in Planned Resources & Cost breakdowns as applicable (optional)

    • i. Save all updates

    • Select “Contacts Tab”

    • j. Convening Authority: Confirm appropriate “Superintendent”

    • k. Inspection Manager: Confirm appropriate ”PVI Manager” or “Process Inspection Lead”

    • l. Confirm Office of Primary Interest:

    • m. CAP Inspector: “PI or person assigned”

    • n. Follow-up Inspector: “PI or person assigned”

    • o. Save all updates

  5. For PVIs, the PVI MANAGER shall:

    1. Send an appointment request to the Team Member(s), for a minimum of 2 days pre-validation preparation, 1 day on-site, and 1 day post validation, using “MS OUTLOOK Calendar” indicating the enterprise name and planned date; 

      Note:

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

      2. Additional time on site may be required for large, complex, multi-functional companies.

      3. The preparation can be done as a group or can be done individually depending on team member locations, schedules and experience levels. There are benefits to both methods. Regardless of which method is chosen the PVI Manager or Process Inspection Lead must ensure effective use of TC resources and that team discussions of issues and the plan for on-site activities are discussed before the scheduled on-site date.

    2. Start the applicable Process Confirmation Checksheet (PVI Appendix A, RDIMS #3977908 or Process Inspection Appendix K RDIMS #5957072); and,

    3. Ensure all Team Members track their actual time spent during each phase of the activity, including travel time.

  6. The Team Member(s) shall:

    1. Block out time in their MS Outlook for pre- (preparation) and post- (assessing etc.) activities. For a PVI, a minimum of two (2) days per phase of the activity is to be blocked out.

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5.2  Rescheduling or Canceling of a PVI or Process Inspection

Note:

1. Rescheduling of an activity refers to the changing of the “planned” date and rescheduling it within the same fiscal year.

2. Cancelling of an activity refers to changing the date or cancelling the activity so it will not be completed within the fiscal year in which it was planned.

  1. If the need arises to reschedule a planned activity, the PVI Manager or Process Inspection Lead will:

    a. Coordinate with the Team Members; and,

    b. Advise the CA of the new date.

  2. The PVI Manager or Process Inspection Lead will update NACIS by:

    Main NACIS Screen

    a. Selecting appropriate company

    b. Selecting audit and inspection tracking tab

    c. Selecting the applicable planned activity

    Select “Planned Tab”

    d. Planned date: Updating “planned date” with the re-scheduled date

    e. Saving all updates

  3. The Team Member(s) will update their MS Outlook Calendar.
  4. If the need arises to cancel a planned activity, the PVI Manager or Process Inspection Lead will:

    1. Complete an entry in the Risk Indicators Assessment Database for all applicable certificates (ie. Operations, Maintenance, DG)

    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.
  5. Once concurrence from the CA has been received, the surveillance activity is then considered cancelled.
  6. The PVI Manager or Process Inspection Lead will:

    1. Advise the Team Member(s) and PI if applicable;

    2. Update MS Outlook;

    3. Finalize the Risk Indicators Assessment Database entry made; and

    4. Document the cancellation by entering the justification in 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 surveillance activity that was planned in NACIS, , do not delete the record from NACIS.
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6.0  PROGRAM VALIDATION INSPECTION ACTIVITIES

6.1  Communications and Client Notification

  1. The PVI Manager is responsible for:

    1. Contacting the PI, advising of the upcoming PVI and obtaining information on the enterprise when required;

    2. Contacting Aviation Enforcement Manager, and requesting a records’ check regarding any issues or enforcement actions (historical or on-going) applicable to the enterprise or key personnel since the last surveillance activity.

    3. Contacting the enterprise key personnel by phone, fax or email to:

      1. Notify the enterprise of intent to perform a PVI;

      2. Confirm the date. If the date is different than the planned date in NACIS Ref 5.1(4) revise NACIS and MS Outlook Calendar as applicable;

      3. Confirm their preference for further communications regarding the PVI ie. Fax, email or post;

      4. Arrange for site facilities and equipment as required;

      5. Identify and arrange for all documents not held by Transport Canada, to be forwarded to the TCC. E.g. Documents incorporated by reference (SOPs, Procedures Manuals, Small Operator Maintenance Control Manual QA Checklists); and

      6. Request pertinent enterprise records be made available on-site during the PVI;

    4. Preparing the PVI Notification letter using the template in Appendix B RDIMS #3977910. This template contains the minimum required content. Items identified in the Notification Letter as optional may be included when required.
    5. The letter is to be sent 6 weeks prior to the PVI, to the enterprise’s Accountable Executive, but no less than 2 weeks without the approval of the CA. A copy of the following must be included:

      NOTE: Blank copies of the Health and Safety Questionnaire and COM forms should be sent to the enterprise to prevent the need for saving blank forms in NACIS. The completed forms are saved into RDIMS when returned by the enterprise.

      1. Health and Safety Questionnaire (Appendix C, RDIMS #3977912)

    6. The notification letter must also include the following:

      1. For an Operational Control PVI on a Fixed Wing 702, 703 or 704 Certificate Holder, print a copy of the Checklist and Guide for the development of a fixed wing company operations manual, which is available on the Transport Canada website at:

        http://www.tc.gc.ca/eng/civilaviation/standards/commerce-manuals-cg-com702-301.htm

        http://www.tc.gc.ca/eng/civilaviation/standards/commerce-manuals-cg-com703and4-302.htm

      2. For an Operational Control on a Rotary Wing 703 Certificate Holder the COM Certification Form RDIMS # 3977915;

      3. For an Operational Control PVI on a 703 or 704 Certificate Holder carrying passengers - the appropriate Safety Features Card Certification Form for the operation (RDIMS #4422076, RDIMS # 4422105 or RDIMS #4422146).

      Note:
      1. The notification letter may also be cc’d to other enterprise representatives if required. e.g. Director of Flight Operations, Person Responsible for Maintenance, etc.

      2. The PVI Notification letter and attachments may be sent by email, facsimile or mail.
  2. If the required documents are not returned to Transport Canada within the specified timeframe, contact the Accountable Executive to request the documents.
  3. If the documents are not received from the Enterprise, consult with the CA for further direction.
  4. The PVI Manager will update NACIS with the PVI Notification letter sent date by:

    1. Select “Actual Tab”

    2. Enter date in: CA letter sent

    3. Save; confirm status changes from Planned to Scheduled.

  5. Enter the RDIMS # of the PVI Notification Letter on the Process Confirmation Checksheet, Item #4.
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6.2  PVI Preparation

  1. The PVI Manager is responsible to ensure:

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

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

  2. PVI Team Member(s) is responsible to ensure flight or train transportation is booked through AMEX Travel AcXess Voyage.
  3. PVI Manager and Team Member(s) are responsible to ensure:

    1. Appropriate time is planned for each phase of the PVI.

  4. Prep time should be planned at least 2 weeks prior to the on-site activity to accommodate for any scheduling conflicts or issues that may disrupt the preparation.

    1. Complex and multi-functional PVI may require additional time for pre, on-site and post PVI activities.

  5. Time is scheduled in MS Outlook for pre (minimum 2 days) and post (minimum 2 days) PVI activities.
  6. When scheduling post PVI activities factor in the time required to review and assess the results, and have the PVI Report sent out to the enterprise within 30 calendar days of the exit briefing.
  7. If preparation is not completed, the PVI Manager must advise the CA to determine whether or not the activity will be re-scheduled or cancelled.
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6.3  Pre-Program Validation Inspection Activities and Documentation Review

  1. Upon receipt of the enterprise’s completed Health and Safety Form and/or other required document e.g. COM Certification, Safety Features Card Certification form, the PVI Manager shall:

    1. Save the document(s) into RDIMS using the applicable TCC 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 Checksheet, Item #7;

    3. Request the specialist(s) review the supplemental documents if they are not part of the PVI Team. e.g. Cabin Safety for the Safety Features Card(s); and

    4. Consult with CA if concerned with comments on the Health and Safety form.

      Note: Aircraft Maintenance and Manufacturing, Commercial and Business Aviation and Dangerous Goods, Flight Training Unit Operations, Air Traffic Services and Airports/Heliports have worksheets referenced in Section 2.1. All other divisions should utilize their existing worksheets.

  2. Obtain the applicable worksheet(s) referenced in Section 2.1.

    Note: To ensure sufficient space for documenting the results of the PVI, single sided printing of the worksheet(s) should be considered. Do NOT double side print any document that will need to be scanned into RDIMS. Ensure that hand written notes are legible to avoid the need to type up the notes/observations.
  3. Conduct the documentation review using the appropriate Worksheet. The objective is to gain an understanding of the systems developed by the enterprise, determine if policies and procedures have been developed for the program and determine if they meet the regulatory requirements. The results of what documents were reviewed and the revisions status should be recorded on the worksheet or on the incorporated attachment.
  4. The documentation review shall include:

    1. A check of the policies and procedures in the manual, or appropriate sections of the manual.

    2. The development of a PVI Plan, Appendix G, RDIMS #5440840. Depending on the scope and complexity of the PVI, not all areas of the PVI Plan are required. Objective, Scope and Depth are the only required fields in the plan. When conducting multiple interviews, include the Interview Portion of the PVI plan, which maybe provided to the enterprise in advance of the on-site activities.

    3. The development of a sampling plan to identify the sample area(s). A Sampling Template is available in RDIMS #4954087. Record on the PVI worksheet the random sampling method used. Stratified sampling details are available in SI-SUR-001 7.8.1 (3) (d).

      Note: The sampling method must be random and repeatable. Examples of random repeatable are computer generated (random number generator) or a record produced on a particular day of the week, e.g. Thursday. A random number generator can be found at http://www.random.org.

    4. The development of questions for the planned interviewees based on their duties. The questions must relate to the expectations, and interviewees level of knowledge of the system; and

    5. The identification of areas of concern that may warrant further review on-site per the applicable worksheet(s).

      Note: 
      1. If a significant or safety related manual deficiency is identified, it can be highlighted for inclusion in a manual non-compliance finding. 

      2. An instruction or procedure must include the details of who does what, where, when and how. 

      3. If it has been determined that the document or section does not meet the regulatory requirements and examples have been identified and documented (three examples are generally required to support a non-conformance) the team is to continue reviewing the document to gain an understanding of the enterprise. 

      4. If significant examples of non-compliance are identified during the remainder of the review, the examples can be used as additional examples or may be used instead of the previously identified examples. Use the strongest examples to support the finding.

  5. In the case of an AMO, stand-alone or with multiple certificates, when the 571.02 Performance Rules Worksheet, RDIMS #3977998 is deemed necessary, the CA approval is required prior to including the additional worksheet to the PVI.
  6. In the case of an AMO with EASA Part 145 Approval, use the EASA Approval Worksheet RDIMS #5290193 in conjunction with the applicable AMO worksheet.
  7. 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 enterprise’s QA Checklists and any enterprise developed procedures for the QA program.

    Note: All other items remain applicable for those who have adopted the SOMCM
  8. The PVI review should cover:

    1. For Operational Control: one year.

    2. For Quality Assurance: two company audit cycles but no more than the preceding two years of enterprise records and include previous surveillance records and any associated findings and corrective action plans.

  9. PVI Manager shall print the Pre-Audit Report from NACIS by:

    • Main Screen

    • a. Operations: Select CBA>OC>

          Maintenance: Select AO>

          General Aviation: Select GA>OC

    • b. Select Reports

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

    • d. Ensure the correct company criteria are shown and click OK.

  10. PVI Team shall review the following sections of the Pre-Audit report for accuracy as compared to TC databases and the approved company manuals:

    1. Company Information Section

    2. Applicable Certificate Information Section

  11. When review is complete, the PVI Manager shall:

    1. Notify the PI or OPI of any updates required;

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

    3. Retain Pre-Audit report as part of the PVI Records.

  12. PVI Team shall review the following information as applicable to the Enterprise’s Certificate(s) including:

    • Mandatory Items:

    • a. Verify legal name and trade name with company files, manuals and NACIS;

    • b. Identify company scope;

    • c. Approved Company Manuals or applicable section, and incorporated by reference documents;

    • d. Company File review - RDIMS and/or Hard Copy;

    • e. Previous audit / inspection / surveillance reports; and

    • f. Exemptions if applicable. Exemptions are retained on File number 2500-1.

    • g. Civil Aviation Daily Occurrence Reports (CADORs);

    • Optional Items:

    • h. Aircraft files;

    • i. Airworthiness Directives;

    • j. If special processes exist, review process specifications e.g. NDT;

    • k. Personnel licence databases to confirm validity of enterprise personnel qualifications and licences;

    • l. Continuing Airworthiness Web Information System (CAWIS);

    • m. Type Certificates;

    • n. Transport Canada databases (e.g. CCARCs, FTAE, AMES, etc);

    • o. Enterprise web page, if applicable;

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

  13. 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. The Inspection and Audit Manual check sheets are available as a guideline for additional areas.

  14. PVI Manager shall ensure all Team Members are familiar the Rules of Evidence prior to on-site activities.
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7.0  PROGRAM VALIDATION INSPECTION ON SITE ACTIVITIES

7.1  Entry Meeting

  1. PVI Manager will convene an entry meeting with enterprise key personnel and the PVI Team. Appendix D, RDIMS #3977921 contains a sample guide detailing discussion points for the entry meeting.

    Note: Let the enterprise decide on appropriate personnel to attend.

  2. Record date, time and all attendees, including TC personnel, and retain as part of the final PVI package.

  3. Details shall be recorded in the space provided on the Entry Meeting Sample, Appendix F, PVI Worksheets or incorporated attachment(s) e.g. extra note pages referred to in the worksheet.

7.2  Physical Inspection

  1. The PVI Team will utilize the applicable worksheet(s) referenced in Section 2.1.

    Note:
    1. Confirmation Request Forms can be used where the Team requires information that is not readily available.

    2. Team Briefings may occur at any time during the PVI if required.
  2. Conduct the On-Site Interview. The objectives of the On-Site Interview are:

    1. To gain a thorough understanding of the enterprise’s processes and procedures;

    2. To determine whether the system described by the interviewee is consistent with the system described in the manual;

    3. To determine whether the system is being used and meets the regulatory requirements; and;

    4. To determine if enterprise personnel understand their system and their duties and responsibilities within the system.

  3. Conduct the On-Site review, which consists of sampling of documents, records and aeronautical products. Refer to SI-SUR-001 for additional information.

    Notes: If an area of non-compliance has been identified, sample to the extent necessary, within the sample size, to ensure the area of concern is not an isolated event, but rather a systemic problem.
  4. The objectives of the On-Site Documents, Records and Aeronautical Products Review are:

    1. To verify the system is being documented as described by the enterprise;

    2. To verify the effectiveness of the Program(s) from the records sampled; and

    3. To verify there are sufficient personnel to support the operation of the Program.

  5. Record the on-site interview and the records reviewed on the worksheets or incorporated by reference attachments. e.g. mind maps, sheets of paper etc. Any discrepancies identified are to be noted and evidence is to be collected to support the finding(s) that show there is a systemic deficiency.

    Note:     If the discrepancy suggests that there is a safety concern, the team members are to determine if safety is or could be jeopardized and deal with the situation accordingly.
  6. Record sufficient detail to support a determination of compliance or non-compliance.

    Note: If a larger space for notes is required, additional pages may be added to the worksheets.
  7. For the on-site interview, as a minimum, record:

    1. Name / Identifier / Licence Number & Position of Interviewee (Name to be removed in report);

    2. Time / Date; and

    3. Pertinent details of interviewees’ responses.

    Note: It is not necessary to ask each question on the worksheet, however each question does require an answer. (e.g. asking one question may result in the interviewee providing answers to several questions).
  8. For the on-site review of documents, records and aeronautical products, record on the sampling plan developed during the pre-inspection activities:

    1. The identification of the document, record or aeronautical product sampled (i.e. type of records, software, parts, aircraft registration, etc; and,

    2. The scope or range (date of training or range, page number, work order number, etc.).

    Note: Documenting additional activities that are performed while on-site is required using the applicable Transport Canada forms. e.g. Aircraft and aeronautical product inspections form(s), training record form.
  9. Gather evidence and/or documentation to support the PVI. The method of gathering any supporting documentation during the PVI includes photocopying, photographing, scanning, etc.
  10. To ensure that the rules of evidence are met for supporting potential enforcement action, the PVI Team Member shall:

    1. Copy the document and then certify it as a true copy and include the date and Inspector’s signature (or delegation stamp) on photocopied document;

    2. Not mark or highlight the document in any other way; and

    3. Secure film or digital memory when taking photographs.

  11. Use the evidence log in Appendix F, RDIMS #3977930 as a receipt when seizing documents.

    Note: When seizing documents, records or aeronautical products refer to CAR 103.09.
  12. The PVI Team will follow the enterprise protocols when handling their documents and records.
  13. A receipt shall be provided for all enterprise documents taken off-site.
  14. If during the PVI safety concerns are discovered, the PVI Team shall deal with the safety issue and carry on with the validation as time permits. If required, advise CA of safety concern and request further direction on the scope of PVI.
  15. If, during the PVI, it is anticipated that the scope or dynamics are going to change, consult the CA. Note: Aviation Enforcement is available to provide guidance or assistance.

7.3  Exit Meeting

  1. PVI Manager shall conduct an exit meeting with enterprise key personnel. Appendix E, RDIMS #3977923 contains a sample exit briefing.

    Note: Let the enterprise decide on appropriate personnel to attend

  2. Record the date, time, attendees (including TC personnel), and relevant discussion points pertaining to issues identified during the PVI and retain as part of the final PVI package.

  3. Details shall be recorded in the space provided on the Exit Meeting Sample Appendix E, PVI Worksheets or incorporated attachment.

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8.0  PROGRAM VALIDATION INSPECTION POST INSPECTION ACTIVITIES

8.1  PVI Report

  1. The PVI Team will:

    1. Conduct an analysis of the worksheets and associated documents generated by the PVI. Refer to SI-SUR-001 14.8.5 for additional guidance;

    2. Document on the worksheet(s) the results of the analysis;

    3. Compare the results of the PVI worksheet(s) against the level 3 expectations to determine compliance or non-compliance for the areas evaluated;

    4. Save the PVI Worksheets into RDIMS (either by scanning directly or saving the electronically created and completed document); and

    5. If the Worksheets have been saved into RDIMS, record the RDIMS reference number(s) on the Process Confirmation Checksheet (Item #16).

      Note: If there is only one person with functional expertise on the team, that team member may consult with other functional specialists (subject matter experts) to determine compliance depending on availability and time constraints.

  2. Where a level 3 expectation or question did not result in compliance, a finding shall be written.

    Note: The expectation that did not result in compliance maybe identified on the finding form to provide a link to the regulatory requirements where applicable.
  3. Based on the results of the PVI, indicate the organization’s score in the report letter, using the criteria provided in the measurement criteria section of the worksheet:

    1. Score of 1: the component or system is not fully documented, not implemented or not functioning.

    2. Score of 2: the component or system is partially implemented but not effective. (Has not met all of the level 3 expectations).

    3. Score of 3: the organization or systems meets all the level 3 expectations

    4. Score of 4: the organizations meet all of level 3 criteria and some of level 5 best practices

    5. Score of 5: the organization meets of level 3 and level 5 best practices

    Note: The CA may be consulted at any time during the PVI if required.
  4. If there is a finding, the enterprise cannot be scored higher than a level 2.

    Note: A score of 2 does not necessarily result in a Notice of Suspension and Enhanced Monitoring. An assessment of the issues must be made using the guidelines in the Enhanced Monitoring Staff Instruction SI-SUR-002.
  5. The completed worksheets are not to be sent out to the companies with the PVI report.

    Note:

    1. When writing findings, a single example of non-compliance can be used e.g. where a enterprise had an untrained pilot who operated an aircraft or an Airworthiness Directive was not complied with, and more than three examples of non-compliance can also be included. The additional examples may be inserted into the Examples section of the finding form or may be attached as an Appendix. In addition a statement at the bottom of the findings section of the finding form indicating that the examples are not an exhaustive list can be made.

    2. Use the best (strongest) examples that demonstrate that the system or process is not functioning or is not compliant.

  6. The PVI Report shall consist of the standardized letter with the non-conformance findings attached per Appendices H and I.

    Note: The Name indicated on the individual finding form(s) can be either the PVI Manager or the PVI Team Member. The PVI Manager in consultation with the PVI Team will make the decision.
  7. The report letter shall be signed by the CA.
  8. Ensure the PVI Report Letter indicates “Protected A” in the appropriate area on each page of report.
  9. 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 a score, interpretation of the finding (minor, moderate, major, critical), corrective action information and enforcement information where applicable;

      Note: Executive Summary details are contained in SI-SUR-001 Section 9.2. Do not include subjective statements, suggestions or recommendations in the report.

    3. Include in the “Non-Conformance With” section of the finding form, the applicable expectation(s) that was not satisfied. This will provide the Certificate Holder with a link between the finding, regulatory requirement and expectation(s) identified in the report letter.

    4. Use the IAM numbering system to identify the appropriate area of non-conformance when drafting the finding; the numbering system does not identify the IAM checksheet used, but rather the area of inspection for NACIS tracking purposes.

    5. Send the PVI report to the enterprise within 10-30 calendar days of the exit meeting. If the 30-calendar day report delivery requirement cannot be met, consult with the CA.

    6. Use a method of delivery that provides confirmation of receipt. When the report is hand delivered, ensure to record the date of delivery on the PVI Process Confirmation Checksheet;

    7. Save the PVI Report to RDIMS; ref: 10.1 and record the RDIMS number on the Process Confirmation Checksheet; and,

    8. 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 enterprise,

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9.0  PROCESS INSPECTION ACTIVITIES

Note: A Process Inspection is a surveillance method not normally requiring appointment of a CA; official notification to the enterprise; opening and or closing meetings; or report to the certificate holder if there are no findings.

  1. When it is determined a process inspection will be conducted, the CASI will ensure:

    1. The CA is notified of the activity;

    2. NACIS is updated with the process inspection date in accordance with Section 5.1(4); and,

    3. MS Outlook is updated with the activity date and name of the enterprise.

9.1  Preparation

  1. Select the process to be reviewed and obtain the applicable Process Inspection Template as listed below. The Process Inspection Template is now the Process Inspection Worksheet for the enterprise.

    1. Process Inspection Template, Safety Profile (RDIMS #4676175)

    2. Process Inspection Template, Performance Measurement (RDIMS #4675951)

    3. Process Inspection Template, Emergency Preparedness & Response (RDIMS #4675907)

    4. Process Inspection Template, Investigation and Analysis (RDIMS #4675876)

    5. Process Inspection Template, Training (RDIMS #4675842)

    6. Process Inspection Template, Generic (RDIMS #5003211)

      Note: To ensure sufficient space for documenting the results of the process inspection, single sided printing of the worksheet(s) should be considered. Do NOT double side print any document that will need to be scanned into RDIMS

  2. Conduct a thorough review of all files and documentation that are relevant to the selected process.
  3. Review of the following maybe required if relevant to the process selected:

    1. Previous assessments, PVIs, or audits including corrective actions and follow-up where applicable;

    2. Accident or incident data, including CADORS;

    3. Previous enforcement action; and

    4. Exemption, waivers, approvals, limitations and authorizations.

  4. Conduct a process analysis using the guidance in SI-SUR-001, Section 17.3 (RDIMS #4650769).
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9.2  On-site

  1. Using the process inspection worksheet created during the documentation review, follow the process from step to step.

  2. Guidance on “tracing”, the method commonly used to follow a process, is available in SI-SUR-001, Section 17.4 (RDIMS #4650769).

9.3  Post Process Inspection Activities

  1. If the process meets the applicable regulatory requirements and is being followed as published, the Process Inspection Lead shall:

    1. Save all applicable documents into RDIMS including the process inspection worksheet;

    2. Update NACIS with the RDIMS # of the process inspection worksheet;

    3. Update ARASS with 1 completion per Process Inspection conducted and record all time using the “Actual Days” task; and,

    4. Make an entry into the Risk Assessment Indicator Database.

  2. If the process does not meet the applicable regulatory requirements for one or more of the following reasons, (i) not document; (ii) not implemented; or (iii) not effective, per SI-SUR-001 Section 17.5, the Process Inspection Lead shall prepare the Process Inspection Report using the template RDIMS # 5957164. The report shall consist of the standardized letter with the non-conformance finding(s). Either the Process Inspection Lead or the CA at the discretion of the CA, can sign the report letter.
  3. Ensure the process inspection report letter indicates “Protected A” in the appropriate area on each page of report.
  4. The PVI Manager shall:

    1. Complete the letter and the findings to compile the process inspection report;

    2. Ensure that the report clearly states the results of the inspection and that it includes corrective action information and Enforcement information where applicable;

    3. Use the IAM numbering system to identify the appropriate area of non-conformance when drafting the finding; the numbering system does not identify the IAM checksheet used, but rather the area of inspection for NACIS tracking purposes;

    4. Send the process inspection report to the enterprise within 10-30 calendar days of the inspection date. If the 30-calendar day report delivery requirement cannot be met, consult with the CA;

    5. Use a method of delivery that provides confirmation of receipt. When the report is hand delivered ensure to record the delivery date on the Process Confirmation Checksheet, item #15;

    6. Save the Report to RDIMS; Ref. 8.1 and record the RDIMS number on the Process Confirmation Checksheet;

    7. Save all applicable documents into RDIMS including the process inspection template;

    8. Update NACIS with the RDIMS # of the process inspection worksheet;

    9. Update ARASS with 1 completion per Process Inspection conducted and record all time using the “Actual Days” task; and

    10. Make an entry into the Risk Indicator Database.

    NOTE: Additional information regarding Process Inspection procedures and the process templates are located in the SI-SUR-001, RDIMS #4650769.
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10.0  PROTOCOLS

10.1  Records Management

  1. RDIMS - The PVI Manager or Process Inspection Lead shall ensure:

    1. All documents that are electronically created for the PVI or Process Inspection are saved into RDIMS; and,

    2. Other documents that support the activity are scanned and saved into RDIMS or paper profiled ie. PVI Worksheets, Process Inspection Template, etc.

      Note:
      Do not scan multiple PVI documents into one RDIMS file or save multiple documents into one email, then save into RDIMS ie. Scan PVI Notification Letter, PCC, and Report into one RDIMS document.

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

    1. Name - enter Program Validation Inspection or Process Inspection…Report or Notification Letter or Worksheet, etc. (as applicable to the document) ABC Airlines May 2003"

    2. Description – optional

    3. Author and OPI – ensure the proper default are selected

    4. Security - select 2 (Protected A) for the PVI/Process Inspection Report and select 1 (Unclassified) for all other PVI/Process Inspection documents

    5. Access - When selecting “Protected A” for the inspection report, the PVI Manager or Process Inspection Lead will ensure that PA and AAR Civil Aviation have read only “Access” rights.

    6. If the Access rights need to be modified, press the “Edit” button and follow the steps below:

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

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

    7. Classification – Press the “Search” button to find the appropriate file classification. Save all PVI and Process Inspection documents into the –17 file (5015-xxxx-17)

      1. All PVI/Process Inspection documents shall be saved to the 5015 file classification except for Approved Training Organizations (5016-XXXX) –, Aerodrome Safety, (5120-X-XXX), Aerodromes and Air Navigation (5151-XXX) and Aircraft Certification (5010-0-XX).
      Note: If the enterprise has a –3 file/ a-4 file, inform Records Management to replace it with a –17 file.
    8. 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 or Process Inspection Lead shall:

    1. Ensure the Process Confirmation Checklist is scanned into RDIMS.

      Note: When the Scanning Request form is used, ensure it include the name in accordance with the naming convention, the number of pages to be scanned and instructions to IM to scan all pages.

    2. Ensure all hard copy supporting documentation that is placed in the enterprise paper files is all paper profiled in RDIMS.

      Note: Any notes created by the team are NOT transitory and must be kept on file.
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10.2  NACIS Updates

  1. The PVI Manager shall update NACIS with the information below, within 10 working days of sending the PVI Report or completing the Process Inspection:

    • Select “Actual Tab”

    • a. Entry meeting date and Exit meeting date;

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

    • Select “Findings Tab”

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

    • d. Enter Follow-up as appropriate.

    • Select “Audit Report Tab”

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

    • f. Reference RDIMS document number of the report in “notes” section

    • Select “CAP Tab”

    • g. Confirm the “ Due date” field has been populated.

    • h. CAP Inspector – PI or person assigned by Superintendent.

    • i. Refer to Tombstone Data section

    • j. Confirm the Status block shows “CAP Due”

    • k. Use Bring Forward function in NACIS to notify the CAP Inspector and the PI of the CAP Due Date

    • l. Ensure PCC RDIMS reference number is entered into the Notes section for the applicable activity.

10.3  Risk Indicator Assessment Database

Note: The database is located on the Ontario Region Intranet Site, Civil Aviation, Audits and Inspections, listed as Risk Indicator Assessment Form.

  1. The PVI Manager or Process Inspection Lead shall:

    1. Update the Risk Indicator Assessment Data Base with entries for all applicable functions (ie. CBA entry, M&M entry, etc.), within 10 working days of sending the report or completing the Process Inspection; and,

    2. Advise the CA when Risk Indicator Assessment(s) have been completed and the applicable functions for which assessments were completed.

  2. The CA shall review the risk assessment(s), complete the “Decision Record” Block and then select “Final Document”.

10.4  ARASS

  1. The CA is responsible for claiming the applicable PVI or Process Inspection completion task in ARASS.

    Note: Only the CA should claim the completion task.

  2. The Team members will claim the actual days (7.5 hours per day) spent on inspection activities. eg. Preparation, on-site and post activities.

  3. The PVI Manager or Process Inspection Lead 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.

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10.5  Process Confirmation Checksheet (PVI or Process Inspection)

  1. Each Team Member will provide the PVI Manager or Process Inspection Lead with their actual time spent during each of the 3 phases of the surveillance activity, including Travel Time.

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

  3. The PVI Manager or Process Inspection Lead will note the date the report was sent (if applicable) on the Process Confirmation Checksheet.

  4. The PVI Manager or Process Inspection Lead shall review the Process Confirmation Checksheet for accuracy, enter their name and date and forward to the CA.

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

  6. The Process Confirmation Checksheet shall:

    1. Be saved into RDIMS if created electronically or depending on TCC protocol (paperless offices) and marked Final; or

    2. If created in hard copy, fill out a scanning request form, send document to IM for scanning and place the original on the hard copy file; and

    3. Enter the RDIMS number of the PCC into the Notes Section of NACIS Audit/Inspection Tab for that activity.

10.6  Communication Protocols

Other Civil Aviation divisions should be advised when unsafe practices or regulatory violations are discovered or when we have information that could impact approvals. When required to contact a TC specialist outside the surveillance Team, consult with PVI Manager, Process Inspection Lead or CA for guidance on the applicable communication protocols.

11.0  APPENDICES

APPENDICES RDIMS #
Program Validation Inspection Process Confirmation Checksheet Appendix A 3977908
Program Validation Inspection Notification Letter Appendix B 3977910
Health and Safety Questionnaire Appendix C 3977912
Entry Meeting Notes Appendix D 3977921
Exit Meeting Notes Appendix E 3977923
Evidence Log Appendix F 3977930
PVI Plan Template Appendix G 5440840
Program Validation Inspection Report – with findings Appendix H 3977939
Program Validation Inspection Report – NIL findings Appendix I 3977946
Operational Support Activities Appendix J 5968729
Process Inspection Confirmation Checksheet Appendix K 5957072
Process Inspection Report – with findings Appendix L 5957164
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12.0  CONTACT

For more information or to provide comments please contact:
Ontario Region Civil Aviation Standards – PAHQ

Phone: 416-952-0326
Facsimile: 416-952-0370

Please forward any comments or concerns to the mailbox at:
E-mail PAStandards-Normes@tc.gc.ca

Original signed by

Joseph Szwalek
A/Regional Director, Civil Aviation
Ontario Region

Date modified:
2012-07-10